4ow WeTreat Wou n ds 



R D 

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librarTof congress. 

tNITEB STATES OF AMEKICA, 





HOW WE TREAT WOUNDS 
TO-DAY 



A TREATISE ON THE SUBJECT OF ANTISEPTIC 

SURGERY WHICH CAN BE UNDERSTOOD 

BY BEGINNERS 



.^^ 



ROBERT t; MORRIS, M. D. 



ILATE HOUSE SURGEON TO BELLEVUE HOSPITAL, N. Y. ; MEMBER LINN^CAN SOCIETY 
OF NATURAL HISTORY, N. Y. ; MEMBER N. Y. COUNTY MEDICAL SOCIETY 





NEW YORK & LONDON 

G. P. PUTNAM'S SONS 

(Jbc Jinithcrbothcr Jlrcss 

1886 



-^ 






COPYRIGHT BY 

ROBERT T. MORRIS, M.D. 



Press of 

G. P. Putnam's Sons 

New York 



FIRST WORD. 



This book is modest only in size. 

It possesses dignity only in its facts. 

There is little of originality in what it 
teaches. 

My idea is to present in digestible form a 
dish of truth from which all bones have been 
removed. 

Experts discuss modifications of Listerian 
principles. 

The rank and file of the profession are too 
busily engaged in practice to be able to follow 
these leaders. 

No one plan of action has been separately 
detailed, and so the great cause suffers. 

I shall attempt to describe concretely the 
way in which a few wounds should be treated. 

Extensiveness will be sacrificed to simplicity. 

The surgeons who are masters of Antiseptic 



JV FIRST WORD. 

Science will learn little from what I have 
written here. 

Other surgeons will find themselves placed 
hand and foot on the ladder which leads up to 
the expert's position. 

These pages can not teach principles. I 
will give you facts and you may deduce prin- 
ciples a posteriorly. 

If enough potential mental energy be devel- 
oped out of the facts to enable stragglers to 
capture the truths contained in the literature 
of Antiseptic Surgery, my object in writing is 
gained. 

The Cumberland, 945 Broadway, 
July I, 1885. 



CONTENTS. 









PAGE 


First Word ........ iii 


General Remarks 






1-25 


Irrigator (Permanent Irrigator, p. 


80) 




26 


Rubber Sheet .... 






27 


Rubber Apron . . , . 






28 


Operating Table 






28 


Instrumemt Receptacles . 






29 


Razor and Brush 






30 


Bichloride-of-Mercury Solution 






31 


Carbolic Acid .... 






34 


Iodoform 






35 


Lister's Protective Oiled Silk 






3^ 


Gutta-Percha Tissue 






37 


Drains 






40 


Silk . . 






t > 

-TO- 


Catgut . . . . 






44 


Silk-Worm-Gut .... 






46 


Lead Strips and Shot 






51 


Sponges 






51 


Bichloride Cotton . . 






5- 


Bichloride Gauze 






53 


Bandages ..... 






55 



VI CONTENTS, 

PAGE 

Towels - . . -55 

Where Materials can be Bought, Price, etc. 56 
General Directions and Explanations . 59-68 

Recent Incised Wound . . . . , 6% 

Inflamed Incised Wound ..... 76 

Wounds in Ovariotomy . . • • • 83 
Wound Remaining Exposed .... 94 

Wound Requiring Frequent Change of 

Dressing ....... 99 

Lacerated and Contused Wound . . . 104 
Inflamed, Lacerated, and Contused Wound . no 
Lacerated Wound . . . . . .112 

Gunshot Wound . 123 

Punctured Wound of Knee .... 127 
Punctured Wound of Palm .... 131 
Inflamed Punctured Wound .... 134 

Poisoned Wound 135, 138 

Burned Wound of Second Degree ; Limited . 141 
Extensive Burn of Second Degree . . . 145 
Burn of Third or Fourth Degree ; Limited . 151 
Extensive Burn of Third or Fourth Degree, 156 
Last Word 162 



HOW WE TREAT WOUNDS TO-DAY- 



CHAPTER I. 

Let us build upon the following syllogism 
which is not of sand. 

All surgeons who understand antiseptic 
wound treatment work antiseptically. 

Not all surgeons work antiseptically. 

Therefore, not all surgeons understand anti- 
septic wound treatment. 

The premises may be challenged by men 
who do not work antiseptically, but at the 
bottom of the trouble is rather the method of 
the individual than any fault in the antiseptic 
method. 

Some men who stand high in the profession 
have expressed themselves as opposed to the 
new and scientific way of treating wounds, but 
this is in fact because they have not had ex- 



2 HOW WE TREAT V/OUNDS TO-DAY, 

perience with clinical demonstrations of genu- 
ine antisepsis and its results. 

Students sometimes excuse themselves from 
an acquaintance with modern methods because 
a certain professor in surgery, for whom they 
have great respect, has not made himself,, 
familiar with the subject. 

Because Cato learned Greek at the age of 
eighty years very few of us are inclined to 
think that the Greek language was previously 
unknown ; and the professor and his students 
will find that time will break down their 
opposition, or, in other words, will supply 
their lack of information. 

Lack of information in this connection 
means that opportunity for learning has not 
been given ; and this opportunity has not been 
widely given in America, because teachers 
have been too few, and because the text-books 
on the subject of antiseptic surgery have 
been too elaborate for beginners. 

In a few years this country will do as good 
or better surgical work than Germany is now 
doing, but in the meantime patients and 
physicians will experience much suffering and 



HOW WE TREAT WOUNDS TO-DAY. 3 

disappointment where comfort and satisfaction 
might be had. 

The history of antiseptic surgery is not dif- 
ferent from the history of previous radical 
advances in civiHzation. 

At present the brightest hghts in the pro- 
fession form the head of the comet, while string- 
ing out into the tail are multitudes who can 
never change their positions. 

In order to fully comprehend our modern 
wound treatment, one must have a knowledge of 
the life-histories of micro-organisms ; although a 
simple appreciation of the fact that microbes 
are continually on the alert for free board 
and lodging would be sufficient to put most 
men on guard against them. 

If you shake a puff-ball the air in the vicinity 
is filled with spores, Avhich become new puft- 
balls so soon as circumstances favor. 

If a septicaemia patient should be shaken, 
the air would in the same way be filled with 
spores, which would proceed to make new 
septicaemia microbes at the very first oppor- 
tunity. 

The micro-oro-anisms, in different stai^'es of 



4 HOW WE TREAT WOUNDS TO-DAY. 

development, which are constantly floating 
about us are successful monopolists ; and they 
betake themselves with their families to any 
spot where a bit of fertile territory is opened 
up — appropriating all food products within 
reach. 

Expose fresh apple juice to the air and 
micro-organisms will fall into it. 

The species which are fond of the sugar in- 
crease most rapidly, and demanding part of the 
elements of the sugar molecule, allow the re- 
maining atoms to arrange themselves into 
alcohol and so-called carbonic-acid gas. — Cider 
results. 

Other species which grow more slowly pro- 
ceed to attack the alcohol, and leave acetic 
acid in its place. — Vinegar results. 

When a large wound is exposed to the air 
many microbes are made happy, and the species 
which feed upon the albuminous discharges be- 
gin work at once ; destroying the plastic lymph 
which is thrown out, and leaving sulphur-alco- 
hols and ethers in their trail. 

The wound has taken on new life, but not 
the kind of new life which we wanted ; and 



now WE TREAT WOUNDS TO-DAY. 5 

irritation, caused by the microbe growth, forces 
nature to resort to a subterfuge in order to 
heal. 

How the old pathologists did love to see an 
abundance of ''laudable pus "! believing that 
its presence with granulating surfaces was a 
thing to be desired. 

Ordinarily, suppuration and undue local 
inflammation are the worst results of the 
growth of micro-organisms ; but if any septi- 
caemia or pyaemia, or erysipelas spores happen 
to be about, they claim a share of the spoils, 
and not content with what is set before them, 
break into and mob the general commissary 
department of the patient. 

We have, however, the power to prevent the 
growth of such micro-organisms in wounds. 

When the surgeons of earlier davs used 
balsams and essential oils in their dressings, an 
approximation to the condition of antiseptics 
was brought about. 

When carbolic acid came into vogue, an 
improvement in wound treatment followed, 
because carbolic acid was a better antiseptic 
substance than oil or balsam. 



6 HOW WE TREAT WOUNDS TO-DAY, 

Bichloride of mercury has proved to be a 
better germicide than carbolic acid. 

Not until Sir Joseph Lister poured together 
into his large crucible, extracts from green- 
growing theories and from cut and dried facts, 
did the pure crystals of antiseptic science 
appear. 

Lister it was who first taught us to apply 
systematically and accurately a method which 
would ensure for our wounds protection 
against the hordes of intriguing microbes, 
and although his particular method has been 
simplified and superseded in other countries, 
the underlying principles remain the same, 
and subtend all the modifications of the im- 
provers. 

To the prime mover in London is due the 
credit of giving to the world a better means 
for preventing suffering than has ever before 
been given by any one man. There are men, 
of course, who will object to this claim ; but 
you cannot argue constitutional law with a 
hod-carrier. Neither can you avoid hearing 
the fire-crackers which pop while the boom o£ 
the cannon is reverberating. 



HOW WE TREAT WOUNDS TO-DAY. J 

It is now possible to gain primary union in 
almost all wounds ; and operators who work 
antiseptically believe as causators that primary 
union goes not by luck but by law ; and 
further, that they are able to inhibit breakers 
of the law. 

Mr. Lister believed his wounds to be aseptic, 
and the belief has caused greater dispute than 
its importance warrants ; for whether or not 
microbes are present in a wound, is a matter 
of no importance, provided that their growth 
be so hindered that natural reparative pro- 
cesses are not interfered with. 

It seems to me that the word antiseptic is 
a better word than aseptic as a qualifyino- 
adjective. 

At the present day we control microbe 
growth with substances which in themselves 
cause so little disturbance to the wound that 
danger from them is seldom to be feared. 
For instance, among hundreds of wounds 
which I have seen in this and in other coun- 
tries, which were treated with bichloride of 
mercury, only one serious case of poisoning 
has been produced 



8 HOJV WE TREAT WOUNDS TO-DAY. 

That case was furnished by a patient of my 
own, and the accident will not occur again, 
although I shall continue to use bichloride of 
mercury until a better material can be substi- 
tuted for it. 

The patient in question will be referred to 
again in another chapter. 

A localized eruption of the skin, caused by 
the carbolic acid or bichloride of mercury 
used in dressings, will appear in perhaps five 
per cent, of our cases, but it amounts to 
nothing, and is preferable to untimely erup- 
tion of the spirit. 

Think of the numbers of patients in whose 
wounds antiseptics make no unwished for 
demonstration. 

Every thing in this world is comparative. 

Think of the numbers who formerly suf- 
fered and died from septic infection, or from 
the effects of prolonged suppuration, because 
antiseptic treatment was omitted. 

Surely sins of omission may be greater than 
sins of commission in surgery. 

Do we deprive patients of an anaesthetic be- 
cause deaths have occurred during anaesthesia ? 



HOW WE TREAT WOUNDS TO-DAY, 9 

Most assuredly not. 

If deaths from such a cause are placed in 
the balance with deaths from shock where 
an anaesthetic was not employed, which side 
do we find the heavier ? 

If we put deaths from corrosive-sublimate 
poisoning on one side of the balance, and 
deaths from wound infection on the other side, 
the latter go down with such a thump that the 
former are hurled high in air and scattered to 
the winds. 

A mild statement is made when we say that 
more misery can be avoided by actual scien- 
tific antisepsis surgery than by anaesthesia. 

Many shadows are thrown on actual scien- 
tific antiseptic by men who suppose that they 
are doing orthodox work when they are really 
doing nothing of the sort. These operators 
hurt the reputation of the cause. 

If an operation should be performed when 
an anaesthetic had carried the patient to the 
stage of excitement only, would an observer 
believe that anaesthesia was greatly beneficial ? 

If a surgeon employ corrosive sublimate or 
carbolic acid in dressing a recent com[Hnind 



lO HOW WE TREAT WOUNDS TO-DAY. 

dislocation of the carpus, and is obliged to 
change the dressings a few days later on ac- 
count of suppuration, does the spectator carry- 
away a favorable idea of antiseptic treatment? 

In either case the fault would lie in the 
method of the individual, but in each case one 
who did not know better would take the prin- 
ciple to task. 

During the first six months of my service 
on the house staff of Bellevue Hospital, in the 
winter of 1882-3, I saw several deaths from 
pyaemia, septicaemia, and erysipelas. 

We believed that our division was doing a 
great deal of antiseptic work, and although our 
records were much better than previous ones 
had been, patients dreaded the very name of 
the hospital. 

In spite of the energetic care of Warden 
O'Rourke, and in spite of the general cleanli- 
ness insisted on by many of the visiting 
surgeons, the dread diseases were almost con- 
tinually present in the wards, and we dared 
operate upon the most urgent cases only. 

If varicocele were operated upon at that 
time by the method of* opening the scrotum 



HOW WE TREAT WOUNDS TO-DAY. II 

Widely, ligating the vessels above and below, 
and snipping out the mass of veins with 
scissors, the patient would have been almost 
certain to develop phlebitis. 

A year later, and the surgeon who lost such 
a case from phlebitis would lose caste in the 
profession, and he would perhaps go back to 
the clumsy old method of ligating the veins 
subcutaneously. 

Subcutaneous surgery and surgery in the 
dark are synonymous. 

In April, 1883, when Dr. Frederick Lange 
introduced scientific antisepsis into the wards 
of the Second Surgical Division of Bellevue 
Hospital, a very active revolution in wound 
treatment followed. 

Dr. Sands at Roosevelt Hospital, Dr. Weir 
at New York Hospital, and Dr. Bull at 
Chambers Street Hospital, in New York, 
were already acknowledged American leaders 
in the new surgery. 

In July, 1883, Dr. Lange went on dut)- as 
Visitinor Surgeon to the Fourth Suro-ical 
Division of Bellevue Hospital, and in not o\\^ 
case from that time until the end of \\\\ service. 



12 HOW WE TREAT WOUNDS TO-DAY. 

in April, 1884, did septicaemia, pyaemia, or 
erysipelas follow operations or attack acciden- 
tal wounds. 

The profuse suppuration to which we had 
become accustomed disappeared as if by 
magic, and instead of spending several hours 
daily in changing dressings, we employed only 
a few minutes in that sort of work, the number 
of operative cases being at the same time very 
greatly increased. 

Patients became enthusiastic and brought 
friends for us to operate upon, and the house 
staff exerted themselves to get series of opera- 
tive cases into the hospital. 

We operated aggressively upon every thing 
which could be operated upon, and we opened 
the great joints and the peritoneal cavity in 
the unclean wards. 

We employed the permanent dressing in 
treating our compound fractures. 

We wired simple fractures of the patella, 
washing out the joints, and the wounds healed 
by primary union. 

The wards lost the old-time hospital odor. 
From a reign of terror we came to a sort of 



HOW WE TREAT WOUNDS TO-DAY. I 3 

millennium as regards microbe invasion, and 
the micro-organism and the wound lay down 
in peace together with a good antiseptic dress- 
ing between them. 

Some one will say that this old and infected 
hospital was very different from a private 
house, and that in the latter place our rigid 
enforcement of precautionary measures would 
not have been required. 

Let me ask a question or two right here. 

Will you, if you live in the purest and fresh- 
est of country air, dare to open the knee-joint 
of a friend and suture a loose semilunar carti- 
lage in place ? 

Can you put a dressing on a badly lacerated 
compound and complicated Potts' fracture and 
allow that dressing to remain untouched for a 
month ? 

Will you treat housemaid's knee or a large 
cold abscess by the simple method of opening 
them freely and trimming out the abnormal 
lining membrane of the cavities ? 

No ! You shiver at the mention if you have 
not yet learned how to work antiseptically ; 
and yet we will treat the cases in this wa\\ 
without hesitation, in our infected hospitals. 



14 HOW WE TREAT WOUNDS TO-DAY. 

A celebrated English laparotomist has been 
loud in his objections to antiseptic wound treat- 
ment, and he champions the cause of extraor- 
dinary cleanliness, without antiseptics. 

In his private hospital and with trained 
assistants he gives us most excellent statis- 
tics, but if he knew how to use antiseptics 
properly he would give us far better ones 
yet. His abdominal wounds would look 
much prettier, and would heal more rapidly, 
and with fewer complications, if he would only 
learn how to treat them antiseptically. 

If any one class of operations can be done 
successfully under extraordinary cleanliness 
alone — the laparotomies form that class. 

Why it is, we cannot at present say. But 
this much we know, that in general surgery* re- 
sults are very mournful when antiseptic treat- 
ment is not employed. 

The fact remains that laparotomies can be 
done successfully without the employment of 
microbe-destroying agents ; but given this fact, 
and how many men are working successfully in 
abdominal operations without depending upon 
antiseptics ? 



HOW WE TREAT WOUNDS TO-DAY, I 5 

Two or three ! 

Give these two or three men a knee-joint in 
which the condyles of the femur have been 
shot through and through by a number forty- 
four Winchester bullet ; and what success 
would they attain in the way of putting the 
patient out of danger from inflammation and 
suppuration ? 

In agreat majorityof cases that leg would have 
to be amputated, and the operators could not 
avoid exhausting suppuration if it were left on. 

We can so manage this wound with antisep- 
tic treatment that the patient will not only 
retain his limb, but he will have almost no 
febrile reaction after the operation. iVnd the 
dressing applied will remain unchanged for 
several weeks. 

Yet these two or three laparotomists have 
the assurance to tell the general surgeons that 
antiseptic precautions need not be considered. 

It is time that we were done with arguing 
exceptions instead of principles. 

An incalculable amount of mischief is done 
by these great men, wlio suffer from astygma- 
tism in one or more of their nuMital lucM'idians. 



1 6 HOW WE TREAT WOUNDS TO-DAY. 

They cannot see the moral horizon of their 
behefs. 

A well-known medical man who has recently- 
been travelling in a foreign country, writes as 
follows with regard to a certain conversation 
which he had with a colleague : 

'' The statement which most impressed me 
was that of a professor of clinical surgery of 
more than thirty years' standing, — a man of 
enormous experience and attached to one of 
the largest hospitals I visited, who told me 
that his deliberate conviction had at length 
been formed, that the so-called antiseptic sys- 
tem had little to commend it save that of 
being a very successful system of quackery." 

Now I happen to know this ''professor of 
clinical surgery " to whom the letter refers. 

I am very certain that he has never seen an 
antiseptic operation in his life, but if he has 
seen one he had no conception whatever of 
the nature of the work. 

His connection with hospital work is at 
present as slender as the stem of a maiden- 
hair fern. 

I have seen, in visits to his ward, numerous 



HOW WE TREAT WOUNDS TO-DAY. I 7 

cases of septicaemia and pyaemia, and tea- 
cupfuls of pus. 

To speak charitably of the man I should say 
— he is too old to learn. 

Were he younger it is probable that in time 
he would come to be a most enthusiastic sup- 
porter of antiseptic doctrines. 

To-day he jumps away like a frog touched 
up from behind if the mention of antisepsis 
be made in his vicinity. 

The surgeon who writes says further : ''He 
put it very much in this way. ' That if from 
time to time, in every few months, the methods 
are changed, and with each succeeding change 
strong statements are made that the last devel- 
opment contains the only security, it must 
inevitably follow that to the public mind there 
can be security only in the hands of the 
inventor himself for the complete and success- 
ful accomplishment of details.'" 

The above explains the extent of knowledge 
which the two men possess on the subject of 
antiseptic surgery. 

Who, I should like to ask, is authorIt\- for 
the idea that ''with each succeeding- chaiv^c 



1 8 HOPV WE TREAT WOUNDS TO-DAY. 

Strong statements are made that the last de-^ 
velopment contains the only security " ? 

Let me tell both of you, and others who 
have had no opportunity of familiarizing them- 
selves with the literature of modern surgery, 
that the supposition expressed above is wholly 
fallacious and malignant. 

Shall we go without watches because differ- 
ent watchmakers are at swords' points as to the 
details of manufacture ? 

No ! All good watches keep time. 

Shall we allow patients to suffer because 
Doctors Popoff and Bonita are not agreed as 
to the relative merits of iodoform and of car- 
bolic acid in wound treatment ? 

No ! Decidedly no ! 

AH good antiseptic methods save life and 
prevent suffering. 

It is high time, too, that every American 
surgeon was at work in the knowledge of that 
fact. 

Mr. Lister has recently received the decora- 
tion of the order of knighthood pour le merite 
from the Emperor of Germany. 

The honor was bestowed over the heads 



HOW WE TREAT WOUNDS TO-DAY, 1 9 

of Langenbeck, Volkmann, and Billroth, and 
even over the heads of the two or three 
laparotomists who urge cleanliness as a sub- 
stitute for antisepsis. 

Is the Emperor of Germany in the habit of 
honoring foreigners in preference to his own 
distinguished countrymen ? 

It was hardly through oversight that this 
thing happened, and never was a better earned 
knighthood than Lister's. 

What men are now doing the advance work 
in surgery ? 

Who are the men who are piling up statis- 
tics of new and great operations ? 

The workers in antiseptic surgery. The 
men who have no fear of inflammation after 
operations. 

Where would McEwen's and Schede's oste- 
otomies stand to-day were it not for antiseptic 
surgery ? 

Who would conscientiously do \^olkmann's 
operation for hydrocele, or Miculicz' tarsus 
exsection, or Petersen's cystotomy, if not as- 
sured that septic infection could be prevented ? 

Could Bruns have reported, in the An- 



.20 HOW WE TREAT WOUNDS TO-DAY, 

nouncement for 1884 of the Tubingen clinic, 
twenty successive excisions of the knee-joint, 
with primary union under one dressing in 
nineteen of them, if he had depended upon 
any method of cleanhness without antisepsis ? 

What do the uninformed think of Esmarch's 
statement before the Twelfth German Medical 
Congress, that out of sixty-three successive 
major operations at his clinic in Halle, fifty- 
eight healed by primary union under one 
dressing ? 

Scientific antisepsis is, after all, only an ex- 
alted degree of cleanliness ; but this exalted 
degree of cleanliness can be reached through 
scientific antisepsis alone. 

A wound is merely put in such shape that 
nature can work uninterruptedly. 

When we operate on bunions, and charge 
the patient a couple of hundred dollars for the 
work which nature does immediately after- 
ward, our consciences are easier than they 
were in earlier days when we charged the 
patient four or five dollars for something to 
put on his bunions, and tried to do the re- 
pairing ourselves. 



HOW WE TREAT WOUNDS TO-DAY. 2 1 

The operation which was really a dangerous 
one a few years ago has become a very simple 
one now that inflammation can be prevented. 

Objection is often made to the small details 
in an antiseptic method. 

The technique and details go to make up 
the grand whole, and whoever omits a part of 
them takes the responsibility upon his own 
shoulders. 

A chain is no stronger than its weakest link. 
An antiseptic system is no stronger than its 
weakest detail, which should have been strong. 

Many physicians suppose that antiseptic 
work cannot be readily carried out in private 
practice, but that hospital facilities must be 
available. 

Let me ask these men if they are going to 
deprive the literary man, the banker, or the 
merchant, of the privileges which are accorded 
the tramp, or the thief who is carried to the 
hospital ? 

As will be shown later it is practically no 
more difficult to do the work in one place than 
in another. 

I have performed in private practice sucli 



22 HOW WE TREAT WOUNDS TO -DA V. 

Operations as ovariotomy, herniotomy, excision 
of the knee, etc., at short notice, and with not 
one essential facihty wanting for the attainment 
of antiseptic ends. 

It is sometimes said that so great pains and 
so much apparatus are required for doing anti- 
septic work that the general practitioner can- 
not carry it out. 

This is in a measure true. 

The time has come when it is best for the 
general practitioner to have as little as possible 
to do with surgery. 

In the country, however, where the physician 
must ride over long distances daily, it is very 
desirable that the art of applying the perma- 
nent dressing be learned. 

When this is accomplished the physician will 
find himself so proud of his results that he will 
be greatly tempted to give up his general prac- 
tice. 

The test of one's ability to do antiseptic 
surgery lies in the success which attends the 
application of the permanent dressing. 

Just as many must fail to comprehend Her- 
bert Spencer s definition of '' life/' so must 



HOW WE TREAT WOUNDS TO-DAY, 23 

many fail to grasp the intention of antisep- 
sis. 

A good old family practitioner of my ac- 
quaintance, who recently put up a fracture of 
the olecranon process in a right-angled position 
with plaster of Paris, was quite sure that anti- 
septic methods were not practical. 

I know a prosperous merchant who hangs 
his barometer out of the window so that pres- 
sure variations can have easy access to it ; but 
this does not reflect upon his ability to lead a 
bull movement in the corn market. 

I am acquainted with surgeons who treat 
amputation wounds by the open method, and 
who would generally have to amputate in a 
gun-shot wound of the elbow-joint in order to 
get a good open wound ; but this does not 
reflect upon their ability to treat typhoid fever 
well. 

The merchant could easily learn something 
about atmospheric pressure. 

The medical men could with comparatively 
little trouble learn to save several weeks of 
healing process after limb amputations, and 
they would seldom think of amputating in 



24 HOW WE TREAT WOUNDS TO-DAY. 

case of compound fracture at the elbow-joint 
so long as circulation of blood continued in the 
hand. 

As far as the open treatment of wounds is 
concerned, the method is as far behind the 
times in surgery as the flint-lock gun is in 
warfare. 

After well-meant attempts at antiseptic work 
some men will still fail to gain expected re- 
sults. 

This is because they do not do antiseptic 
work. 

The man who jumps over a brook and lands 
well on the bank is satisfied with the result of 
his effort. 

The man who jumps almost across, but not 
quit^, is in a very different mood. 

There is a considerable difference between 
jumping entirely over a brook, and jumping 
almost over it. 

The one who falls short will make the most 
noise. 

Let him who can shoot ruffed grouse be the 
first to describe the bad qualities of red Irish 
setters. 



HOW WE TREAT WOUNDS TO-DAY, 2y 

Let him who can apply a plaster of Paris 
jacket properly be the first to say that Sayre's 
way of handling spondylitis is not the best 
way. 

Let him who can apply a permanent dress- 
ing to a compound fracture at the ankle-joint. 
be the first to decry antiseptic surgery. 



CHAPTER II. 

From the infinite variety of apparatus and 
materials which belong to antiseptic surgery, I 
shall select for description enough to enable 
the reader to do thoroughly good work in 
private practice. 

In order to prevent confusion, I purposely 
avoid even the mention of much more that is 
equally useful, and prefer to make no refer- 
ence to the elaborate apparatus which we 
employ in the hospitals. 

THE IRRIGATOR. 

Buy at the druggist's a fountain syringe of 
four quarts' capacity. 

Use the nozzle which will throw the strong- 
est single stream. 

Hang the irrigator on something near the 
operating table and three or four feet higher 
than the top of the latter. 

Pour in the antiseptic solution which you 

26 



HOJV WE TREAT WOUNDS TO-DA V. 2/ 

are going to use, a few minutes before begin- 
ning an operation. 

Give the whole care of the apparatus to one 
assistant, and instruct him to keep the wound 




The Irrigator. 

and the skin in its vicinity almost constantly 
wet while you are working. 

He will wash away blood easily with the 
little stream and will help keep the operative 
field in the light. 

THE RUBBER SHEET. 

A. piece of rubber dam, or of heavier rubber 
stuff, is one of the most necessary parts of an 
outfit. 

The sheet should be six feet long by three 
feet wide. 

It is placed under the patient, or any part of 
him, and is gathered up when in use in such a 
way that fluids will run into a catch-pail 
below. 

Clothes-pins which close with a spring are 



28 



now IVE TREAT WOUNDS TO-DAY. 



useful for gathering up the sheet or for fasten- 
ing it to blankets or clothing. 

Wash the sheet thoroughly after every 
operation, and immerse it in i-i,ooo bichloride- 
of-mercury solution before drying. 




Rubber Sheet, arranged for operation upon the leg. 

THE RUBBER APRON. 

An apron made from the same material as 
the sheet, and long enough to reach from the 
neck to the feet of the operator, is required for 
keeping the clothes dry and clean. 

The apron should be washed after every 
operation. 

THE OPERATING-TABLE. 

In almost any house in the civilized world a 
table which is suitable for operative purposes 
may be found. 



HOW WE TREAT WOUNDS TO-DAY. 



29 



It should be so placed that a good light 
from a neighboring window will fall upon it. 

Blocks of wood should be placed under two 
of the legs of the table, in order to allow 
irrigating fluid to gravitate toward the end or 
side where the catch-pail stands. 

INSTRUMENT RECEPTACLES. 



Place a small table and a chair near the 
operating-table. 

h 




ROUGH AND READY. 



1. Saucers for catgut, needles, etc. 

2. Bottle of Lister protective. 

3. Bottle of drainage-tubes. 

4. Bottle of iodoform. 

5. Large bowl for rinsed sponges. 

6. Small bowl for artery forceps, etc. 



7. Bottle of silk-worm ^^ut, silver 

wire, etc. 
S. Wash-bowl for rinsing sponges. 
9. Wash-bowl for preparing towels- 

and hands. 

10. Large platter for large instruments. 

11. Small platter for small instruments. 



30 HOW WE TREAT WOUNDS TO-DAY. 

On the small table put a roast-beef platter 
for large instruments ; a large bowl for clean 
sponges ; a small platter for small instruments, 
and two or three saucers for catgut, needles, 
etc. 

On the chair place the large wash-bowl, in 
which sponges are to be rinsed out. 

Fill the instrument platters with an 1-30 
solution of carbolic acid. 

Fill the saucers for catgut with the alcohol 
in which the catgut has been stored. 

Fill the wash-bowl with an 1-2,000 solution 
of bichloride of mercury. 

THE RAZOR AND BRUSH. 

For cleaning the skin before an operation, a 
sharp, narrow-bladed razor and a nail-brush 
are necessary. 

Rub a wet piece of soap over the surface 
of the skin, and shave carefully, no matter 
whether any visible hairs exist or not. 

Scrub off the soap with the nail-brush, and 
rinse with an 1-1,000 bichloride solution at the 
same time. 



HOW WE TREAT WOUNDS TO-DAY, 3 I 

BICHLORIDE-OF-MERCURY SOLUTION. 

Fill an eight-ounce bottle with hot water. 

Add sixteen grains of powdered bichloride 
of mercury to each ounce of water. 

Take this bottle along in your valise when 
going out to operate. 

One ounce of this solution to the quart 
of water will make approximately an i-i,ooo 
solution. 

Bichloride solution, of the strength of 
1-1,000, will kill microbes in a few moments, 
and is not harmful to the patient, if used in 
the right way. 

If a large quantity be left enclosed in a 
wound, or in an uterus after an intra-uterine 
douche, trouble is likely to follow. 

Dry the wound with a moist sponge — to use 
a Hibernianism, — or wash awav the strono- 
solution with a final dash of 1-5,000 sohition. 

As a matter of fact, it is seldom necessary 
to use the 1-1,000 solution about a recent 
wound. 

It is used principally for cleaning the surface 
of the skin in the vicinity of the wound, for 
cleaning the surgeon's hands Ix^fcM'c^ beginning 



32 HOJV JVE TREAT WOUNDS TO-DAY. 

an operation, and for washing out the inter- 
stices of a wound which is not sweet. 

For a long while I used the i-i,ooo solution 
exclusively for irrigating, and for general anti- 
septic purposes, and had no resulting trouble. 

Finally I poisoned a patient with it. 

After amputating at the middle of the thigh, 
I allowed a considerable quantity of the strong 
bichloride solution to remain in the wound 
when the latter was closed. 

A few hours afterward the patient began to 
complain of intense pain along the region of 
the descending colon. 

This pain continued for about a week. 

The patient was obstinately constipated. 

The pulse was continually rapid and not 
strong. 

The temperature was slightly elevated. 

He suffered from constant nausea. 

He was salivated. 

The operation in itself had caused little 
constitutional disturbance, as the man was 
clear-headed and preferred to sit propped up 
in bed so soon as the effects of the ether had 
passed away. 



HOW WE TREAT WOUNDS TO-DAY. 33 

There was no inflammatory reaction in the 
wound. 

By the tenth day after the operation all of the 
distressing symptoms were rapidly on the wane. 

On the twelfth day the dressings were 
changed for the first time. 

A wager had been made before the opera- 
tion that the tissues would be completely 
united by primary union on this day. 

The tissues were not completely united by 
primary union. 

They were practically not united at all. 

There was no sign of inflammation about 
the wound, and it looked very much as it did 
a few moments after the operation. 

The wound began to granulate finely so 
soon as the symptoms of poisoning had dis- 
appeared, and it healed readily by granulation. 

It is an interesting fact that the bone drain- 
age-tubes and the catgut sutures had been 
absorbed completely in the usual way at the 
time when the first dressing was removed, 
notwithstandino- the unchanoed condition of 
the tissues about the wound. 

I would poison every such patient in this 



34 HO IV IFE TREAT WOUNDS TO-DAY. 

way rather than expose him to the dangers 
which hover about a wound which has not 
been treated antiseptically. 

I shall never again poison such a patient 
with bichloride of mercury. 

I shall continue to use bichloride of mercury. 

If an 1-2,000 bichloride solution is em- 
ployed for irrigating purposes, etc., and if the 
solution be not left in a wound in large quan- 
tities, the danger from bichloride poisoning 
must be a very far removed one. 

An 1-5,000 bichloride solution is the best 
one to use for washing out the peritoneal 
cavity, and for washing large synovial cavities 
and the interior of the uterus. 

It is often advisable to use a strong solution 
for a few minutes, and then to give a final 
washing with the solution 1—5,000. 

In the great majority of cases the best all- 
around solution is the 1—2,000 one. 

CARBOLIC ACID. 

For all carbolic-acid purposes an 1-30 watery 
solution is sufficient. 

The instruments in the dishes are covered 



HOW WE TREAT WOUNDS TO-DA Y. 35 

with this solution before being used at an 
operation, and they are placed back in it when 
not in use during the operation. 

Bichloride of mercury in solution should 
not be used in the presence of metals. 

A precipitate forms rapidly. 

The jars and bottles in which are stored 
sponges, sheet lead, Lister protective, silk, 
rubber drainage-tubes, etc., should be filled 
with the carbolic-acid solution. 

IODOFORM. 

Iodoform is an exceedingly useful accessory 
antiseptic substance. 

It is dusted over the surface of a wound which 
is to remain open, or along the line of suture, 
and about the mouths of the drainage-tubes in 
a closed wound. 

The numerous other occasions for the use of 
iodoform will suggest themselves to the surgeon 
so soon as he appreciates the fact that serous 
and other discharoes vntsf remain sweet when 
they are impregnated with a sutticient cpiantity 
of this druo-. 

If a large amount of iodoform (^knir to cMght 



36 HOW WE TREAT WOC/A^ES TO-DAY. 

drachms) be used on an open wound, toxic ef- 
fects, marked by continued mild delirium, a 
rapid and feeble pulse, and a remittent temper- 
ature running up to 102° Fahn, may supervene. 

I have used the drug constantly in varied 
surgical work and have seen two cases of poi- 
soning. Both of these were extensive burn 
cases, and I used about an ounce at a time on 
the exposed surfaces. 

In cases of poisoning by iodoform the symp- 
toms usually disappear rapidly if the un- 
absorbed portion be removed. 

There is no danger connected with the use of 
iodoform, provided that the surgeon be aware of 
the fact that there is danger connected with the 
use of iodoform. 

The drug may be compared with whiskey in 
the above respect. 

The amount of iodoform which is required 
for covering an ordinary wound falls far short 
of being a dangerous quantity. 

lister's protective oiled silk. 

This is smooth and unirritating. A strip 
which is wide enough to cover the sutures 
should be used on a closed wound. 



HOW WE TREAT WOUNDS TO-DAY. 37 

Tear holes in the protective opposite the 
mouths of the drainge-tubes so that serum may 
easily percolate through the neighboring gauze. 

A piece which is a little larger than any 
given open wound should be placed upon the 
wound ; so that epithelium cells which are 
working their way across the granulations will 
not become entangled and discouraged in the 
gauze or cotton. 

We can all remember the barbarous days 
when dressings stuck to wounds and when it 
hurt the patient to change dressings. 

The protective, to be ready for use, should be 
torn into strips and put into large-mouthed 
bottles which are filled with the carbolic-acid 
solution. 

GUTTA-PERCHA TISSUE. 

A very thin and flexible waterproof material 
possessing a wide range of usefulness. 

The dressing on a small wound will some- 
times dry too quickly, and allow the adhering 
of cutaneous margins by an other than patho- 
logical process, before the discharge of scrum 
from the deeper tissues has stoppcxl. 



38 HOW WE TREAT WOUNDS TO-DAY, 

Serum dammed up in the wound presents a 
mechanical obstacle to repair ; as organization 
of the plastic lymph is obviously thus inter- 
fered with. 

Cover small dressings with gutta-percha 
tissue and they will not become too dry. 

Very moist dressings are as much to be 
avoided as very dry ones, and if the dressing 
have become soaked with serum, it is best to 
change it for a fresh one. 

It will seldom be necessary to make more 
than one such change in any one case. 

In operations about the head, in which the 
irrigating solutions and blood may run into 
the eyes or through the hair of the patient, a 
wide strip of gutta-percha tissue can be fast- 
ened by one margin to the skin of the fore- 
head in such a way that the remainder of the 
piece will fall over the parts to be protected. 

For preventing rapid evaporation from the 
skin, and for purposes of general neatness in 
abdominal operations, a large sheet of the 
gutta-percha tissue is fastened to the abdomen. 

A sufficiently large hole is cut in the centre 
of the piece before applying, and the margins 



HOW WE TREAT WOUNDS TO- DA V. yj 

of the opening then surround the operative 
field. 

When an injured Hmb is to be elevated, and 
permanent irrigation employed, the gutta- 
percha tissue is invaluable ; a piece being fast- 
ened about the limb in such a way that water 
is prevented from running down along the 
limb toward the body. 




I. Loosely bandaged gauze dressing. 2. Gutta-percha tissue. 

The tissue is best fastened to the skin ac- 
cording to the method of Dr. Woodward, 
which is as follows : 

As much gutta-percha tissue as will dissolve 
in chloroform is put into a small bottle full of 
that liquid. 

The mixture is ready for use in a few min- 
utes. A camel's-hair brush is wanted. 

Draw the brush full of the solution quickl\- 
along that part of the skin where the margin 
of gutta-percha tissue is to be attached. 

Apply the margin which is to be attached. 



40 HOW WE TREAT WOUNDS TO-DAY. 

Wait a moment for softening to take place^ 
and then put fresh, narrow strips of the tissue 
along the soft and sticky edge. 

Don't draw the brush over the gutta-percha 
tissue unless you want to get into an armful- 
of-oars predicament. 

Tissue which is to be used in the vicinity of 
a fresh wound must be washed in bichloride 
solution before being applied. 

DRAINS. 

Serum or blood when locked up in a wound 
delays repair. 

Drainage-tubes made from decalcified bone 
are inserted into a wound in such a way that 
serum and blood may escape. 

The tubes collapse in a few hours after in- 
sertion. They are usually completely absorbed 
by the tenth day, and the opening left in the 
tissues is usually closed by the fourteenth 
day. 

Cases have been reported in which a much 
longer time was required for absorption of the 
bone tubes. I am inclined to believe that in- 
flammatory processes were allowed to go on in 



HOW WE TREAT WOUNDS TO-DAY. 4 1 

the wounds in which these tubes have remained 
unabsorbed. 

It is best to put a disinfected safety-pin 
through the projecting end of the tube, in 
order to prevent it from sHpping in under the 
skin. 

Keep the bone drainage-tubes stored in 
alcohol. 

Rubber drainage-tubes must be used where 
pressure of surrounding tissues would collapse 
the bone drains too quickly. 

Some surgeons employ rubber drains ex- 
clusively. The tubes of this material have one 
objection : 

They must be removed after their period of 
usefulness in a wound has passed. 

The dressing must be changed in order to 
remove the tubes. 

I do not like to change a dressing until the 
wounci has healed. 

Before inserting a rubber tube, bend it 
sharply at the junctions of its half inches, and 
cut off the resulting angles with a pair ot disin- 
fected scissors. 

Tubes of proper size and shape are thus 



42 HOW WE TREAT WOUNDS TO-DAY. 

made. After insertion into a wound, the 
tubing which projects above the skin should 
be cut off and a disinfected safety-pin stuck 
through the end which Hes at the surface. 

A tube which I inserted into the wound, 
after doing an operation for the radical cure of 
bubo, was not supported by a safety-pin. 

The tube disappeared beneath the skin. 

The wound healed over the tube, and I was 
obliged to cut it out later. 

Keep the rubber drainage-tubes in bottles 
of 1-30 carbolic-acid solution until they are 
ready for use. 

Catgut drains are desirable for small wounds. 

Serum will find its way along a single strand 
of catgut, just as urine finds its way along a 
filiform bougie. 

Any number of strands of catgut may be 
bunched together in order to make the drain 
larger or smaller. 

Soak the strands in 1-2,000 bichloride solu- 
tion for fifteen minutes before using them for 
drainage purposes. 

Catgut swells rapidly in watery fluids. 

If it be taken out of alcohol and used di- 



HOW WE TREAT WOUNDS TO-DAY. 43 

rectly as a drainage-conducer, the swelling 
strands will close the gates against departing 
serum. 

SILK. 

Silk has had its day. 

Surgeons who work antiseptically still em- 
ploy it occasionally for special suturing and 
ligating. 

I use it for sutures about the eye, because a 
more delicate strand can be made from it than 
from catgut ; and for ligating haemorrhoids, 
because such great strength is required in 
order to properly cut off the connection be- 
tw^een the pile and the rest of the patient. 

Silk should be kept in a bottle of 1-30 
carbolic-acid solution. 

Keep only a small amount ready for use, 
because it loses its strength after standing for 
several weeks in the solution, and a fresh 
preparation will be required from time to 
time. 

CATGUT. 

For general suturing and ligating purposes 
ordinary catgut should be used. 



44 HOW WE TREAT WOUNDS TO-DAY, 

Sizes 8, 7, and 5 are most often required, in 
their respective order, number 8 being the 
smallest of the three. 

Raw catgut is prepared antiseptically as 
follows : 

Put the skeins in a bottle full of oil of 
juniper, and let them stay there for two or 
three days. 

The oil of juniper dissolves out the fixed oil 
of the gut. 

Empty out the oil and rinse the skeins with 
alcohol. 

The alcohol dissolves all oil. 

Put the skeins in a wide-mouthed bottle 
filled with commercial alcohol, and keep them 
in the alcohol until wanted for use. 

Be sure and tie catgut ligatures with a 
square knot. 

Hold the knuckles of your thumbs together 
when tying so as not to throw artery forceps 
out of the window when the gut breaks. 

If the knot is to be subjected to considera- 
ble tension, a double square knot is required. 

Don't cut the free ends of gut too close tO' 
the knot. 



BOW WE TREAT WOUNDS TO-DAY. 



45 



For fastening the free end of gut after tak- 
ing the last stitch in a continued suture I would 
suggest the following method : 

Leave two inches of free end when you cut 
off the surplus part of the strand. 

Run the needle and surplus part of the 
strand once more through the skin in the 
usual interrupted suture way. 

Tie the interrupted suture with a square 
knot. V 




KNOTS FOR HOLDING CATGUT ENDS, IN A CONTINUED SUTURE. 

1. Firmly tied ordinary slipknot, 3, Free end of continued suture. 

2. Lme of incision in skin. 4,4 Free ends of interrupted suture. 

5. All knots tied. 

Tie one of the free ends of the interrupted 
suture gut in a square knot with the free end 
of the continued suture gut. 

Catgut is usually completely absorbed by 
the end of the tenth day after its introduction 
into the tissues. 

The smallest size sometimes disappears 
during the first week. 



46 HOW WE TREAT WOUNDS TO-DAY. 

A delicate variety of catgut, put up in car- 
bolized oil, is found in the drug stores, and 
this sort will sometimes be wanted for suturing 
intestine or nerves, or for face work. It is 
altogether too expensive for general use. 

CHROMIC CATGUT. 

Sometimes a durable form of catgut is re- 
quired. 

If it be prepared with chromic acid it does 
not begin to disappear before the fourteenth 
dav. 

The process of preparation is a rather com- 
plicated one (see '' Antiseptic Surgery," by 
W. Watson Cheyne, M. B. , F. R. C. S. London : 
Smith, Elder, & Co., 15 Waterloo Place. 1882. 
Pp. 57 and 58), and consequently it will be 
best to buy ready for use what little is 
needed. 

SILK-WORM-GUT. 

The unspun fluid of the silk-worm, which 
would have been silk if spun, has been long 
used by fishermen for making leaders and 
snells. 



HOW WE TREAT WOUNDS TO-DAY, 47 

It is Strong, smooth, unirritating to the tis- 
sues, and is never absorbed. 

Silk-worm-gut is stronger than silver wire of 
the same thickness, and is very flexible. 

Surgeons have recently been using it for 
a variety of purposes. 

I am especially fond of using it for sup- 
porting tissues which would otherwise strain 
too heavily on the catgut sutures. 

For instance, after amputation of a large 
female breast, the catgut sutures are subjected 
to a disturbing degree of tension. 

This can be obviated in the followino- wav : 
Thread a large needle with one strand of silk- 
worm-gut. 

Pass the gut transversely across the wound, 
and so deeply that each end of the strand will 
emerge from the skin at a point situated a 
couple of inches from the margin of the 
wound on its corresponding side. 

Thread the needle with successive threads, 
and repeat the process until enough have 
been inserted into the flaps to hold the latter 
in fairly close apposition. 

Don't fasten the ends until kitcr. 



48 HOW IV E TREAT WOUNDS TO-DAY. 

Usually four or five such sutures are needed. 

This IS the first step in the operation of 
closing the wound. 

The next step would be the suturing of the 
flaps with catgut and the insertion of drainage- 
tubes. 

The last step consists in fastening the silk- 
worm-gut sutures. 

They have lain loosely in the tissues while 
the other work was being done. 

A couple of inch-and-a-half wide strips of 
sheet-lead are now taken from the dish of car- 
bolic-acid solution. 

Each one is about half as long as the wound, 
and is perforated with a row of small holes 
running along its middle. 

The ends of silk-worm-gut which project 
from one of the flaps are passed through holes 
in the strip of lead. 

A perforated B.B. shot is slipped over each 
end of silk-worm-gut on that side, and is 
mashed on the gut with a pair of strong forceps. 

Twitch each of the free ends of silk-worm- 
gut on the opposite flap to see if the shot are 
going to hold. 



HOW WE TREAT WOUNDS TO-DA V. 49 

An assistant next holds both flaps so firmly 
together that the catgut sutured part is loose 
and lax. 

The other strip of sheet lead and the shot 
are passed over the remaining free ends of 
silk-worm gut. 

The shot are pinched hard. « 

The assistant removes his hands. 

The strain comes on the broad lead plates, 
and the line of catgut sutures is relieved of 
much responsibility. 

Change the dressings for the first time at 
the end of the second week. 

Remove the lead strips and the silk-worm gut. 

The catgut and drainage-tubes will have 
disappeared by absorption. 

The old-fashioned method of supporting 
tissues with plasters, and which was devoid of 
mechanical tone, may be done away with in its 
entirety. 

There is no excuse for the use of plaster 
about wounds of any kind at the present day. 

Silk-worm-gut will in many cases take the 
place of silver wire for fastening together the 
fragments of bone in a compound fracture. 



50 HOW WE TREAT WOUNDS TO-DAY. 

It will perhaps be necessary here to twist 
three or four strands together. 

Tie the gut in a firm square knot and cut 
the ends off as closely as you please. 

The knot will not slip easily. 

Silk-worm-gut would seem to be desirable as 
a suturing material in Bank's hernia operation. 
If the fibrous margins of the abdominal wound 
are brought into apposition by means of sutures 
of the material in question, placed one third of 
an inch apart, the margins must stay in posi- 
tion until sufficient plastic lymph has been 
thrown out for the purpose of repair. 

The ends of the silk-worm-gut are cut close 
to the knot. 

The sutures remain indefinitely. 

The previously necessary pad, the pressure 
of which caused more or less absorption of 
the plastic deposits, may be done away with. 

The cutaneous wound closed with catgut 
sutures should heal with great regularity by 
primary union. 

Silk-worm-gut should.be kept ready for use 
in a bottle of 1-30 carbolic acid-solution. 

It is soft and flexible when first removed 



ERRATA. 



Page 5, 6th line from bottom, for antiseptics read antisepsis. 

Page 9, loth and 12th lines from bottom, antiseptic and anti- 
sepsis should exchange places. 

Page 20, 9th line from top, for Halle read Kiel, 

Page 93, description of cut, Suture and sutures should ex- 
change places. 

Page 112, heading, for laceration read contusion. 

Page 159, 12th line from bottom, for dressing xQ2id face dress- 
ing. 



NOW WE TREA T WOUNDS TO-DA Y. 5 I 

from a watery fluid, but becomes too hard for 
use in a few moments if allowed to dry. 

LEAD STRIPS AND SHOT. 

The strips of lead previously referred to 
may be whittled out of sheet-lead with a jack- 
knife. 

Bore the holes in these and in the shot 
with an ordinary awl. 

Scrape rough edges which would irritate the 
skin. 

Put the strips and the shot in the carbolic- 
acid solution along with the instruments before 
beginning an operation. 

Cut the strips into any desired length as oc- 
casion requires. 

SPONGES. 

For ordinary surgeon's purposes use selected 
reef sponges. 

Buy them by the pound. 

They do not cost much, and the surgeon 
can throw them awa)' after employing them 
once. 

Prepare the sponges as follow s : 

To one ^rallon of water add eiL^ht tluid 



52 HOW WE TREAT WOUNDS TO-DAY. 

•ounces of a saturated solution of permangan- 
ate of potassium. 

Put in half a pound of sponges. 

To another gallon of water in another ves- 
sel add three fluid ounces of concentrated 
hydrochloric acid and one ounce of hyposul- 
phite of soda. 

After the sponges have remained in the 
permanganate solution for fifteen or twenty 
minutes, take them out one at a time. 

Squeeze them as dry as possible. 

Toss them into the acid-and-salt solution. 

Add a fresh lot of the acid and salt so soon 
.as the last thrown-in sponges fail to turn white. 

Remove the bleached sponges. Squeeze 
them. 

Put them where they will become very dry. 

Hire a boy to beat out the sand. Put what 
sponges are wanted for use in the near future 
into fruit jars filled with 1-30 carbolic-acid 
solution. 

At an operation a few of the sponges are 
removed from the jar, squeezed out, and 
thrown into the bowl of 1-2,000 bichloride-of- 
mercury solution. 



HOW WE TREAT WOUNDS TO -DA V. 53 

A clean, empty bowl on the table will hold 
the sponges after they are rinsed and 
squeezed. 

Flat sponges and other valuable varieties 
may be recleaned and used repeatedly as 
follows : 

Wash out blood and other contents as thor- 
oughly as possible. 

Put the sponges in a vessel of water. 

Set the vessel in a warm place. 

As soon as decomposition has broken down 
the fibrin which was entangled in the sponges, 
they are to be washed in clean water and then 
put through the original bleaching process. 

I use sponges only once, and have prefer- 
red to throw away a couple of dozen in the 
course of a week rather than run any risk 
which might attend a second using of any one 
lot. 

BICHLORIDE GAUZE, 

Cheese-cloth, mull, and other gauzy stuffs 
are deprived of all fatty material, and arc then 
impregnated with an i-i,ooo solution of 
bichloride of mercury. 

The process of manufacture is a complicated 



54 HOW WE TREAT WOUNDS TO-DAY, 

one, and it is best to buy the gauze ready 
prepared. 

Serous discharges from a wound percolate 
readily through this material, — especially if a 
handful of it be crumpled up before applying, 
and the contained mercuric salt going into 
solution in the serum prevents all fermentative 
processes. 

On account of the large interstices in the 
gauze, a too rapid drying is apt to go on, and 
consequently a layer of bichloride cotton in 
large dressings, or of gutta-percha tissue in 
small dressings, is necessary. 

BICHLORIDE COTTON. 

An absorbent cotton prepared with an 
i-i,ooo-solution of bichloride of mercury is 
more economical than gauze as a dressing. 

The cotton does not remove discharges, 
from the region of a wound so rapidly as the 
gauze removes them. 

It is best to use a layer of several thicknesses 
of gauze in the immediate vicinity of a wound, 
and to cover the gauze with a thicker and 
larger layer of the cotton. 

Buy the cotton ready prepared. 



HOW WE TREAT WOUNDS TO-DAY. 55 

BANDAGES. 

Bandages of gauze, prepared with bichloride- 
of-mercury solution, should be used for hold- 
ing dressings in place. 

TOWELS. 

Dressings ought to be cut and prepared on 
clean towels just before an operation, and then 
rolled up in the towels ready for use. 

An assistant, whose hands are unprepared, 
must touch only the outside of the towels. 

Clean towels, wrung out in 1-2,000 bichloride 
solution, are placed about every thing near a 
wound, in such a way that hands, instruments, 
sutures, etc., cannot come in contact with any 
thing which is not antiseptically prepared. 

The towels must be watched and kept in 
place. 

I have seen an absorbed operator allow the 
silk for an abdominal ligature to trail across a 
leucorrhoeal vulva, supposing that towels were 
so arranged as to prevent the silk from squirm- 
ing around into any unclean place. 

The patient died of septic peritonitis ; but 
then several drops of perspiration from the 



56 HOW WE TREAT WOUNDS TO-DAY. 

Operator s face, three or four hairs from art 
unshaven mons veneris, and part of the con- 
tents of an ovarian cyst, went into the abdomi- 
nal cavity along with the silk ligature. 

The abdominal cavity in this case was care- 
fully cleaned after the operation w^ith a sponge, 
which had fallen on the floor only once. 

The operator is not convinced that antisep- 
tic precautions offer great advantages over 
simple cleanliness, as he states in an article 
relating to the subject. 

Patients go from great distances to this 
surgeon and allow him to start botanical 
gardens on their insides. 

All this in connection with towels. The 
little digression in the last paragraphs seems 
to be justifiable. 

WHERE MATERIALS CAN BE BOUGHT. 

L. H. Keller & Co., 64 Nassau St., New 
York, sell raw catgut. 

In lengths of one metre each : 

PRICE. 

Eight dozen metres of No. 8 . . . . $0-75 

Seven " " " 7 . . . . .75 

Six " '' '' 6 . . . . .75 

Five '' '' " S . ^ . • 'IS. 



HOW WE TREAT WOUNDS TO-DAY, 57 

In lengths of five metres each : 











PRICE. 


One dozen lengths 


No. 


(= No. 


8 short) 


$0.50 


u u a 


a 


i( " 


7 " ) 


•5° 


(( a ic 


a 


2( " 


6 " ) , 


.85 


a u a 


u 


3( " 


5 " ) . 


I. 10 



McKesson & Robbins, wholesale druggists,. 
New York, furnish sponges. 

PRICE. 

Mixed reef sponges, per pound . . . $1.50 
Assorted reef '' <' ^< ... 1.75 

Any druggist can supply the fountain syr- 
inge, which is used as an irrigator. 

PRICE. 

Capacity three or four quarts . . $i-5o to $2.50 

Powdered bichloride of mercury, ) 

Iodoform, >• Varying with druggist. 

Carbolic acid, ) 

Dealers in fishing tackle have silk-worm-gut 
on hand. 

PRICE. 

In bunches of 100 strands . . . :8>2.oo to $3.00 

Separate strands .... .02 to .03 

Chas. G. Am Ende, Hoboken, New Jersey, 
furnishes general antiseptic supplies. Here 
are a few quotations from his list : 



58 



HOW WE TREAT WOUNDS TO-DAY, 



Rubber dam. Three feet by six 
Rubber cloth, i| yard wide, per yard . 
Gutta-percha tissue, per yard 
Bone drainage-tubes. No. i, smallest, to No. 4, 
largest, per dozen ...... 

Rubber drainage-tubes. No. i, smallest, per y'd 

H U H ii ii 

" 3, most used 

u a a ii 

4 

Bichloride of mercury gauze ; absorbent, 

Five-yard tins, per dozen 
Eichloride of mercury cotton ; absorbent, per 

pound ....... 

Bichloride of mercury gauze bandages, per doz 



PRICE. 

$3.00 to $3,50 
2.00 

.35 



5 


a Ljy i J. 

" 4 


inches 


5 


" 2 


ii 


5 


" 4 


a 


5 


" 3 


a 


5 


" 4 


a 



Chromic catgut, and delicate prepared catgut of 
varieties, at special prices^ 



3-50 
.50 
.60 

.70 
.80 

•15 
9.00 

1.25 

.50 
.60 

.70 
.80 
.90 

I. GO 

Other 



CHAPTER III. 

When a wound has been made the surgeon 
is called upon to recognize the presence of : 

First. Injured tissues which nature will re- 
pair to a greater or lesser extent. 

Second. Effused fluids which will conduct 
repair. 

Third Parasites which live at the expense 
of the wound fluids. 

The surgeon's first duty is to remove obsta- 
cles to repair. 

Obstacles to repair are principally mechani- 
cal and chemical. 

Mechanical : as when lint, salve, fragments 
of bone, etc., remain in contact with raw sur- 
faces ; or when loss of tissue prevents adapta- 
tion of parts. 

Chemical : when microbes grow in the dis- 
charges and cause fermentation. 

The latter obstacle to repair is the more 

59 



6o HOW WE TREAT WOUNDS TO-DAY. 

difficult of removal, but is not at all hard to- 
prevent if we begin in time. 

If a cutting operation is to be done, or if an 
accidental wound is to be dressed, we must 
first prepare the skin by getting out of the 
way as many of the present microbes as 
possible. 

General directions, then, are as follows : 

Shave that part of the skin which is to be 
covered by an important part of the dressing. 

Shave the most delicate and cleanest skin as 
well as the roughest and most hairy. 

Scrub the shaved part with a soft brush and 
soap-suds in order to remove loose superficial 
epithelium. 

Wash away the soap-suds with i-i,ooo bi- 
chloride-of-mercury solution. 

Wring out light towels in 1-2,000 bichloride 
solution, and put them where they will protect 
from all unprepared objects in the vicinity ; 
arranging them so that instruments, catgut, 
fingers, etc., shall touch towels and towels 
only, when not employed during the opera- 
tion. 

Hands which are to come in contact with the: 



HO IV WE TREAT WOUNDS TO-DA V. 6 1 

wound, or which are to touch instruments, ap- 
paratus, or dressings, must be washed and 
scrubbed thoroughly in i-i,ooo bichloride 
solution before the operation is begun. 

These same hands must be rewashed when- 
ever any unprepared object is touched during 
the operation. 

Instruments which were made scrupulously 
clean after the last previous operation, are to 
be put into an 1-30 carbolic-acid solution for 
half an hour or more before beine used, and 
they are to remain in the carbolic acid when 
not in use as work proceeds. 

All handling of dressings, catgut, sponges, 
etc., must be very cautiously done, and con- 
stant watch must be kept on attendants who 
are liable to violate any antiseptic rule. 

Dressings should be prepared on clean tow- 
els before the commencing of an operation. 

During the open-wound part of an operation 
the irrigating solution should be frequently 
squirted over the region of work — dampening 
the skin, the exposed deep tissues, the hands 
of the operator, and the ardor of the mi 
crobes which are settlino- on forbidden ground 



62 HOW WE TREAT WOUNDS TO-DAY, 

When a wound is being closed, drainage 
must be provided for by means of strands 
of catgut, absorbable bone drains, rubber 
tubing, or any other suitable means for the 
end. 

After the wound has been closed, iodoform 
should be sprinkled along the line of sutures 
and over the ends of the drains, for the pur- 
pose of fortifying the position strongly against 
fermentation. 

Prepared Lister protective (Chapter IL) 
should then be placed over the line of su- 
tures, to prevent any irritation from the 
other parts of the dressing, and to prevent 
the adhering of any part of the dressing to 
the region of the wound or to the sutures. 

A handful of mussed-up bichloride gauze 
must be placed loosely about the wound, to 
allow of easy percolation of serum. 

Enough more bichloride gauze or cotton to 
catch and retain the serum must be added. 

If you don't guess closely enough on the 
amount of gauze and cotton required in any 
one case, and serum runs through to the out- 
side of the dressing, a good sprinkling of iodo- 



HOW WE TREAT WOUNDS TO-DAY. 63 

form must be tossed over the moist places, and 
more gauze or cotton added. 

Don't change the dressing because serum 
has run through it. 

The serum is so thoroughly impregnated 
with iodoform and bichloride of mercury that 
it cannot decompose. 

Don't change the dressing, as a rule, until 
you believe the wound to be healed. 

There are perhaps five indications for 
changing dressings before the wound has 
healed : 

First, when rubber drainage-tubes need to 
be removed. 

Second, when troublesome secondary hem- 
orrhage occurs. 

Third, when the operation has not been 
done antiseptically and high temperatures 
give warning of mutiny in the forecastle. 

Fourth, when plastic operations or other 
supplementary work must be done. 

Fifth, when the surgeon's curiosit}' is ramjv 
ant and uncontrollable. 

Concerninof case first : the dressing- nuist be 
removed under irrigation and with disinfected 



64 HOJV WE TREAT WOUNDS TO-DAY, 

hands ; the new dressing being as carefully 
prepared as the first. 

This having been done the second dressing 
may remain undisturbed for weeks if necessary. 

In regard to case second, secondary hemor- 
rhage is one of the rarest of wound complica- 
tions if the operations have been antiseptically 
managed. 

If a large artery be ligated at a point near 
any of its branches, or if the ligature be loosely 
tied, or if small arteries be overlooked because 
a weakened heart fails to force blood through 
their contracting mouths, then of course sec- 
ondary hemorrhage may be expected. 

The old-fashioned and much dreaded hem- 
orrhages of pus days are not at present 
admitted into cultivated surgical circles. 

The third case of necessity for a change of 
dressing, — a septic condition of the wound, — 
would cause a good deal of criticism among 
the surgeons who hold modern views. 

However, it is perhaps necessary to put un- 
certain operators on their guard against allow- 
ing mischief of serious character to follow a 
septic accident. 



now WE TREAT WOUNDS TO-DA Y. 65 

If on the day after an operation the patient's 
temperature should arise to 102° F., with a full 
and hard pulse accompaniment, a saline cathar- 
tic and aconite must be given. 

This temperature will not infrequently fol- 
low an operation which causes much constitu- 
tional disturbance, and it will remain for a few 
hours. If the temperature reach 102° F. on 
the second day after an operation, it would be 
advisable to change the dressing and examine 
the wound, unless an evident outside cause for 
the temperature existed. 

If at any time during the course of wound 
repair the temperature should reach 102' F. 
on two successive days, a careful examination 
for the cause of such temperature should be 
made. 

Open treatment would probably be called 
for if marked inflammation about the wound 
were found to exist. 

A very little experience in antiseptic surgery 
will teach the operator how to avoid having 
such a case. 

The fourth cause for change ot dressing 
needs no comment at present. 



66 HOW WE TREAT WOUNDS TO-DAY. 

As to the fifth cause, we notice that it is 
almost impossible for men who are just be- 
ginning to do good surgery to leave dressings 
alone. 

They are so accustomed to a different order 
of things that a great deal of moral courage is 
required for holding in abeyance the Borean 
blasts of curiosity which clamor for release. 

In scientific antiseptic surgery the mechani- 
cal obstacles to repair must be handled in a 
radical way. Tissue which is likely to slough 
should be trimmed away before closing a 
wound. Sloughs of small size will be rapidly 
absorbed but large ones may excite suppuration. 

All bleeding from the small vessels in a 
wound should be effectually attended to, even 
if much time is required for doing it. 

The small clots as well as the large ones 
should be removed before a wound is closed. 

The wound must be so shaped if possible 
that like tissues may be coapted. 

The coapting sutures must, as foreign bodies, 
be so arranged as to be undisturbing. 

Serum and late oozing blood must find easy 
departure from the recesses of the wound. 



HOW WE TREAT WOUNDS TO-DAY. 6/ 

Motion in wounded tissues delays or prevents 
repair, and must be guarded against ; tender 
new growth needing protection in animal as 
well as in vegetable tissues. 

Most of the obstacles to repair excite inflam- 
matory processes in the wound if they are not 
prevented from doing so by the surgeon. 

When I speak of inflammation I do not 
mean to include the hyperaemia of repair. 

Inflammation and the hyperaemia of repair 
allow of diflferentiation. 

With the former we have swelling, pain, and 
abnormal heat and redness. 

With the latter we do not have swellino-, 
pain, and abnormal heat and redness. 

There may be an insensible gradation be- 
tween the two conditions, just as Ave find an 
insensible color gradation in man between the 
African and the Anorlo-Saxon races. 

Negroes are not often mistaken for Scan- 
dinavians. 

Inflammation should not be mistaken for the 
hyperaemia of repair. 

A wound may be defined as a limited inter- 
ruption in the continuit)' of the tissues ot an\' 



'68 HOW WE TREAT' WOUNDS TO-DAY. 

living organism, caused suddenly by violence 
acting through any instrument or agent. 

This definition will include such burns as 
are essentially wounds but which have usually 
been excluded from classification among the 
wounds. 

Wounds as best classified are incised, lacer- 
ated, contused, punctured, poisoned, or burned. 

Under each class I shall describe an artificial 
series of varieties. 

A description of the treatment for a few 
types in wounds will serve for giving an idea 
of the course which would be followed in 
analogous cases. 

Class i. Incised Wound. Variety i, A 
Recent Wound. 

A butcher has received a cleaver-cut across 
the front of the wrist. 

He comes to you an hour or two later with 
a handkerchief tied tightly about the wound. 

A casual examination shows that the cut has 
extended into the carpal joint, and that the 
styloid process of the radius is split off. 

The patient does not wish to take ether, but 
his wishes are to be ignored. 



BOPV WE TREAT WOUNDS TO-DAY. 69 

Have a couple of assistants at hand. Pre- 
pare instruments and apparatus. 

Get the following things ready : 

The rubber sheet. 

The irrigator filled with 1-2,000 bichloride- 
of-mercury solution. 

A large dish filled with 1-2,000 bichloride 
solution for washing sponges. 

A dish filled with 1-1,000 bichloride solution 
for washing the clotted blood, etc., from the 
patient's wrist, for cleansing the hands of oper- 
ator and assistants, and for moistenino- towels. 

A dish filled with 1-30 carbolic-acid solution 
for scalpels, artery-forceps, retractors, scissors, 
needle-holder, etc. 

A wide-mouthed bottle filled with No. 8 and 
No. 7 catgut in alcohol. 

A small bottle of chromic catgut. 

A wide-mouthed bottle full of Lister pro- 
tective in 1-30 carbolic-acid solution. 

Iodoform. 

Bichloride gauze. 

Bichloride cotton. 

A skein of catgut in a saucer of 1-2,000 
bichloride solution. 



70 HOW WE TREAT WOUNDS TO-DAY. 

Two or three bichloride-gauze bandages. 

A razor and nail-brush. 

Soap. 

Prepared sponges. 

Apply Esmarch's bandage or the tourniquet 
to the patient's arm. 

Lay the hand and wrist on a part of the 
rubber sheet, and arrange the latter so that it 
will allow irrigating fluids, etc., to run into the 
catch-pail. 

Wash away blood-clots, etc., with i-i,ooo 
bichloride solution. 

Wash the skin in the vicinity of the wound 
with soap-suds, and shave the surface for a dis- 
tance of several inches above and below the 
wound. 

Wash off the soap-suds with i-i,ooo bichlo- 
ride solution. 

Wring out a towel in i-i,ooo bichloride 
solution, and spread it on the rubber sheet 
under the hand and injured wrist. 

Place another towel of the same sort on the 
arm above the wrist. 

Put another prepared towel where it will 
catch instruments, catgut, etc., which are laid 
aside now and then during the operation. 



HOW WE TREAT WOUNDS TO-DA Y. J\ 

Scrub your hands in the i-i,ooo bichloride 
solution. 

Ask an assistant to begin irrigation with the 
1-2,000 bichloride solution, and to continue 
the irrigation at intervals while work proceeds. 

If you take the irrigator-tube in your hand 
at any time during the operation, don't forget 
to dip this hand in 1-1,000 bichloride solution 
before again touching the wound. 

If a sponge fall on the floor, let it stay there. 

Don't pick it up ; and allow no one to 
touch it. 

It might accidentally get back into the 
region of the wound again. 

The regularity with which such sponges 
usually return to the wound is only exceeded 
by the regularity with which some operators 
give the wound a final dab with the cleaning- 
up towel. 

If an instrument be laid on the bare table, or 
if it touch any unprepared object, in fact, that 
instrument must go back into the carbolic-acid 
solution before being employed again. 

If an assistant in handing you a piece of 
catgut allow the catgut to touch his coat- 



72 HOW WE TREAT WOUNDS TO-DA V. 

sleeve, the strand must be put back into the 
alcohol and a new one substituted. 

On making an examination of the wound, the 
following condition of things is found to exist : 

The cleaver has incised the skin cleanly, and 
has severed the tendons of the palmaris longus^ 
flexor carpi radialis, extensor ossis metacarpi 
pollicis, extensor primi internodii pollicis, flexor 
sublimis digitorum, flexor profundus digitorum, 
and flexor longus pollicis muscles. 

The cut ends of the tendons have retracted, 
and the sheaths are open. 

The median nerve and the radial vessels 
have also been cut in two. 

The radial styloid process is separated from 
the radius. 

The joint is found to be widely opened." 

According to old views, this wound would 
be a dangerous one. 

Treated according to modern views, this 
wound will give the surgeon no anxiety and 
will cause the patient almost no pain. 

In wounds of this character inflammation 
and suppuration can be prevented with mathe- 
matical certainty. 



HOW WE TREAT WOUNDS TO-DAY, 73 

Pull the margins of the wound far apart 
with retractors. 

Wash the exposed portions of the synovial 
cavity with the irrigating solution. 

Fasten the separated styloid process in place 
with a bit of chromic catgut passed through 
the periosteal margins, or through little holes 
drilled for the purpose. 

Approximate the fragments closely, in order 
to insure primary union between them. 

Find next the median nerve. 

If the ends have retracted until they are out 
of sight, cut for them. 

Cut until you find them. 

When the ends are found, they are to be 
sutured together with one or more delicate 
strands of catgut. 

Hunt for the ends of the divided tendons. 
If they have retracted until they are out of 
reach, cut until they are within reach. 

If an end of palmaris longus tendon be 
sutured to an end of median nerve, there is 
great danger of the sutures becoming absorbed 
before the nerve has learned to pull o\\ ihe 
palmar fascia. 



74 HOW WE TREAT WOUNDS TO-DAY. 

Suture tendons in their respective continui- 
ties, that functional proprieties be not shocked. 

Tie the catgut with a firm, square knot, 
and then tie another knot of the same kind on 
top of it, when suturing the tendons. 

It is not necessary here to suture the cut 
margins of synovial membrane. 

Ligate the cut ends of the radial artery with 
No. 7 catgut. 

Remove the tourniquet. 

Ligate smaller bleeding vessels with No. 8 
catgut. 

Wait until all oozing of blood has stopped. 
Take the skein of swollen catgut out of its 
saucer of bichloride solution. 

Cut seven or eight short strands from it. 

Bind the strands loosely together with one 
of their number. 

Put one end of the bunch as deeply in the 
wound as it will go. 

Allow the other end of the bunch to project 
externally. 

This little bunch of catgut will act very 
thoroughly as a drain and will cause no dis- 
turbance. 



BOW WE TREAT WOUNDS TO-DAY, 75 

Fasten skin margins together with inter- 
rupted catgut sutures. 

Don't let an edge of skin turn under when 
the sutures are tightened, and avoid a too close 
suturing in the vicinity of the drain. 

Sprinkle iodoform along the line of suture. 

Take an inch-wide strip of Lister protective 
out of the antiseptic solution in which it has 
been stored and lay it over the wound, tearing 
a hole in it opposite the drain. 

Muss up a handful of bichloride gauze and 
place it loosely about the wrist. 

Flex the hand strongly, and apply a bandage 
of bichloride gauze in such a way that it will 
remain flexed. 

Wrap a big wad of bichloride cotton about 
the hand and wrist and lower half of the arm. 

Tell the patient to carry his arm in a sling 
until the dressing is changed. 

Change the dressing for the first time after 
three weeks have elapsed. 

Suppuration will not occur in this wound : 
when the dressings are removed, the gauze in 
the vicinity of the wound will be discolored 
and slightly moist. 



76 BOW WE TREAT WOUNDS TO-DAY. 

A drachm of transparent gelatinous dis- 
charge will be found adhering to the protec- 
tive. The dressing will smell as sweet as new 
bread. 

No trace of the catgut sutures or drain can 
be found. 

Begin passive motion gradually, and con- 
tinue it vigorously. 

Apply the galvanic current to the muscles 
of the hand which receive nerve supply from 
the median nerve. 

Continue treatment until enough improve- 
ment has been gained. 

Class i, Incised Wound; Variety 2, An 
Inflamed Wound. 

A patient who has received the same injury 
as that described under Variety i, comes to 
you three days after the accident. 

When the wrist was cut the man called on 
''the nearest doctor," who treated the case 
as follows : 

The wrist was washed off under the warm 
water faucet. 

The cut ends of the radial artery were 
ligated with ordinary surgeon's silk from a 



HOW WE TREAT WOUNDS TO- J) AY. J J 

skein which was fished up from the depths of 
the dressing-case. 

The artery-forceps which were used '' looked 
pretty clean." 

Half a dozen sutures from the skein which 
furnished leaven for the radial artery hold the 
skin margins together. 

The local newspaper correspondent said 
that Ebenezer Grain cut himself so badly that 
Doctor Smith was obliged to put six stitches 
in the wound. 

Sheet lint on which vaseline was spread 
covered the wound, and the patient was ad- 
vised to keep this dressing moist with carbolic- 
acid solution, — signa : teaspoonful in a pint 
of water ; use as directed, — and to return on 
the next day. 

The patient kept the dressing wet fairly well 
during the first day, but at night it was not 
convenient to wake up every few minutes and 
attend to it. 

The skin wound united. 

The dressing dried so that serum could not 
escape. 

The menagerie began to increase rapidly 
by young born in confinement. 



78 HOW WE TREAT WOUNDS TO-DA V. 

Inflammation set in. 

The doctor coincides with the patient in the 
belief that the wound healed too quickly. 

The wrist is hot, swollen, red, and very 
painful, and there is marked tenderness along 
the sheaths of the tendons. 

The patient's temperature is elevated ; his 
pulse is full and hard, and he is in a condi- 
tion of general unrest. 

On cutting away the sutures and separating 
the margins of the wound, a quantity of 
grumous discharge escapes. 

A drop of this discharge will, under the 
microscope, be found to be swarming with 
multitudes of microbes of different species. 

Open treatment from the first would have 
been better than such closed treatment. 

With open treatment the patient would 
only have lost the use of the tendons and 
of the median nerve, and of the carpal joint, 
and of four fifths of the hand, and the wound 
would not have required more than two months 
for cicatrization to be completed. 

With closed septic treatment, however, a dan- 
gerous inflammation is thrust upon the patient. 



HOW WE TREAT WOUNDS TO-DA V. 79 

Make a free opening into the carpus on its 
dorsal side. 

Flush the old wound and the new one with 
1-1,000 bichloride-of-mercury solution. 

Wash out the joint by throwing a stream of 
the 1-1,000 bichloride irrigating solution forci- 
bly into it, twisting and bending the carpus 
rapidly while this is being done. 

Wash so thoroughly in this way that the re- 
turning fluid is perfectly clear. Spend ten 
minutes in doing the washing. 

Slit up the openings of the synovial sheaths 
of the tendons- and squirt them repeatedly full 
of the irrigating solution. 

Remove the fractured styloid process of the 
radius. The chances of necrosis and delayed 
repair do not warrant us in leaving it. 

Sprinkle iod6form on all reachable parts of 
the wounds. 

Wrap eight thicknesses of bichloride gauze 
about the hand and wrist and lower part of the 
arm. 

Fasten the gauze in place with a Ux^sely ap- 
plied gauze bandage. 

Put the patient in bed. 



8o 



HOM^ WE TREAT WOUNDS TO-DAY. 



Tell him that he must stay in bed for about 
ten days. 

Give him a saline cathartic. 

Lessen arterial tension with aconite. 

Give refreshing drinks and light diet. 




THE PERMANENT IRRIGATOR AT WORK. 

1. Perpendicular slat. 4. Bandages for suspending arm. 

2. Bed. 5. Pitcher for antiseptic solution, 

3. Small stick with drip-rope attached. 6. Rubber tubing acting as siphon, 

7. Drip-rope. 

Arrange a permanent irrigating apparatus as 
follows : 

Fasten a strong upright slat to each end of 
the bed. 

Another slat should extend between the 
tops of the two upright ones. 



HOW WE TREAT WOUNDS TO-DA V. 8 I 

Suspend the whole arm by means of loops 
of broad bandage from the overhead slat. 

Hang a pitcher on one of the upright slats. 

Don't substitute a metallic pail for the 
pitcher, because a precipitate will be at once 
thrown down from the bichloride solution. 

Fill the pitcher with 1-5,000 bichloride-of- 
mercury solution. 

Hang a couple of feet of drainage tubing 
over the edge of the pitcher in such a way that 
it will act as a siphon, and draw away the an- 
tiseptic solution in a small, steady stream. 

Suspend over the wrist a small improvised 
rope of cotton twine in such a way that the 
stream will run along it. 

Turn down ends of the twine at distances 
of an inch apart, so that the solution will drip 
constantly from these ends. 

Prevent the water from running down tow- 
ard the patient's body along the arm by fasten- 
ing a piece of gutta-percha tissue around the 
arm below the elbow (Chapter H.\ 

Arrange any rubber sheet on the bed under 
the arm to catch drippings, and lead thcni into 
a pail. 



82 HOW WE TREAT WOUNDS TO-DAY, 

Don't allow the pitcher of antiseptic solu- 
tion to run dry. 

In eight or ten days, or, rather, so soon as 
you feel confident that inflammation has 
ceased and that the wound is granulating w^ell, 
the permanent irrigating apparatus is to be 
removed. 

The wound must heal by granulation, and 
consequently the suturing of the median nerve 
and the ends of the cut tendons will not prom- 
ise much. 

It is best, however, to suture the structures 
in question, because it is possible to get restora- 
tion of function in the nerve, and the tendons 
will act in opposing the extensors of the 
fingers and wrist, even if they do not assert 
their individuality. 

Even if the median nerve fails to recuperate, 
the ulnar will pursue the even tenor of its way, 
and will continue to supply the muscles of the 
little finger, the interossei, the two inner lum- 
bricales, the adductor pollicis, and the inner 
head of the flexor brevis pollicis, so that a very 
much better than an artificial hand will be 
left 



now IV E TREAT WOUNDS TO-DAY. 83 

The tendons and the median nerve are to be 
sutured. Do not suture the skin wounds. 

Do the work with all of the scientific antiseptic 
precautions which were described under Variety 
I , and do it in the same way as though the wound 
were a recent one. 

Dress the wound as Variety i was dressed. 

Do not change the dressing until three weeks 
have passed. 

The pus corpuscles from the granulating sur- 
faces will be so few in number that the slight 
amount of semi-solid discharge will not appear 
either macroscopically or microscopically as pus. 

After-treatment will be of the same character 
as after-treatment in Variety i, but a good deal 
more of it will probably be required, and the 
ultimate results will be far less satisfactory. 

A considerable amount of useful hand will 
be left the patient in all events, and amputation 
of the hand or arm will have been avoided. 

Class i, Incised Wound ; Variety 3, An 
Operative Wound. 

A case of cystic tumor of the right ovary is 
to be operated upon. 



:84 HOW WE TREAT WOUNDS TO-DAY, 

The tumor weighs about twenty pounds ; 
possesses a long pedicle ; and has given rise 
to no serious inflammatory disturbances. 

Every operator prefers his own way of man- 
aging the mechanical side of an ovariotomy, 
and I describe a method here for the single 
purpose of bringing in the antiseptic features 
•of the operation. 

The room in which the patient is to be 
handled should be heated to more than 80° F., 
so that shock from chilly intestines may be 
avoided. 

The air of the room should be filled to 
saturation with moisture, for the same pur- 
pose, — surface evaporation being prevented 
by the measure. 

The following things are required : 

Rubber sheet. 

Irrigator filled with 1-2,000 bichloride solu- 
tion. 

Wash-bowl full of 1-5,000 bichloride solu- 
tion for washing sponges. 

Empty bowl for washed sponges. 

Ordinary and flat sponges which have been 
bleached and stored in 1-30 carbolic-acid solu- 
tion. 



//OJV WE TREAT WOUNDS TO-DAY, 85 

Bowl of 1-1,000 bichloride solution for wash- 
ing hands ; for the patient's skin ; and for wet- 
ting towels. 

Large platter filled with 1-30 carbolic-acid 
solution for the large instruments and lead 
strips. 

Smaller platter filled with 1-30 carbolic-acid 
solution for small instruments. 

Wide-mouthed bottle of No. 7 catgut in 
alcohol ; containing also a catgut violin string 
of large size for the pedicle ligature. 

Small bottle of chromic catgut. 

Wide-mouthed bottle of silk-worm-gut in 
1-30 carbolic-acid solution. 

Wide-mouthed bottle of Lister protective in 
^carbolic-acid solution. 

Iodoform. 

Bichloride gauze. 

Bichloride cotton. 

Gutta-percha tissue. 

Gutta-percha solution. 

Broad bandage. 

Binder and safety-pins. 

Razor and brush. 

Soap. 



86 HOIV WE TREAT WOUNDS TO-DAY, 

Towels. 

Spread the rubber sheet on the operating^ 
table and elevate the head end of the latter. 

Place the patient on the table and anaes- 
thetize her. 

Cover her limbs and chest with woollen 
blankets. 

Shave the abdomen and the mons veneris. 

Spend a couple of minutes in getting the last 
flake of loose epithelium out of the smallest 
crease in the navel. 

Wash the soap from the abdomen with 
i-i,ooo bichloride solution, and scrub the skin 
with the nail-brush at the same time. 

Wash a foot-square piece of gutta-percha 
tissue in i-i,ooo bichloride solution, and then 
cut a four-inch long and two-inch wide hole in 
the middle of it. (Thick American g.-p. t. is 
the best.) 

Fasten this gutta-percha tissue to the ab- 
domen with gutta-percha solution (Chap. II.), 
arranging the piece so that the hole will in- 
clude that part of the abdominal surface where 
cutting is to be done. 

Wring out three towels in i-i,ooo bichloride 



HOW WE TREAT WOUNDS TO-DA V. 8/ 

solution and place one of them across the 
patient's thighs. 

Tuck the upper margin of this towel under 
the lower margin of the gutta-percha tissue. 

Lay another towel on the abdomen and 
chest. 

Tuck the lower margin of this towel under 
the upper margin of the gutta-percha tissue. 

Place the third towel on that part of the table 
where instruments will be temporarily laid 
while you are working. 

The hands of all persons who are manually 
interested in the operation must be scrubbed 
in i-i,ooo bichloride solution. 

Cut through the abdominal wall to the right 
of the median line. 

Irrigate. 

Cut at a point which is far enough to the 
right so that the knife will pass through rectus 
abdominis muscle. 

A cut through muscular tissue heals much 
more quickly and firmly than a cut through 
fibrous tissue does. 

Don't use the irrigator after the peritoneal 
cavity is opened. 



88 ' HOW WE TREAT WOUNDS TO-DAY. 

When the tumor is reached the patient is to 
be turned over on her right side. 

Don't guess that you can get along without 
turning the patient on her side. 

Watch the next operator who works without 
attention to this precaution, and you will be 
convinced of the necessity, for giving a position 
advantage when at work on a tumor, the fluidi 
contents of which are to be evacuated before 
the tumor is removed. 

Hold the tumor firmly against the opening 
in the abdominal wall with vulsellum forceps. 

Tell the assistants to be sure and hold fast 
with the forceps when an opening into the 
tumor is made. 

Keep an eye on the assistants. 

Be sure that their forceps are holding the 
tumor in such a way that none of the contents 
of the cyst can get into the abdominal cavity. 

Open the cyst widely with a scalpel. 

Wash out the contents of the cyst quickly 
with the stream from the irrigator, and dry 
the cyst cavity with a large sponge. 

Leave the sponge in the cavity. 

Close the opening with a pair of catch forceps. 



HOW WE TREAT WOUNDS TO-DAY. 89 

Leave the forceps in place. 

Separate the walls of the tumor from adher- 
ing surroundings. 

Ligate the pedicle in two places, an inch 
apart, with the largest catgut string from your 
wife's favorite guitar — the string having been 
borrowed ten days previously and prepared in 
oil of juniper and alcohol. 

Remove the tumor from its pedicle by 
cutting between the two ligatures. 

Ligate the ends of the large vessels of the 
pedicle separately with No. 7 catgut. 

Drop the pedicle back into the abdominal 
cavity. 

Insert one hand into the abdominal cavity 
in such a way that intestines will be held back 
by the back of the hand. 

The finger-tips then go into Douglas' cul 
de sac. 

Call for the pitcher full of warm 1-5,000 
bichloride solution. 

Pour a quart of this solution into the hole 
which your hand keeps open. 

Remove all blood clots and small bits of 
loose tissuewhich are floated outbv the llushinL:. 



go HOW WE TREAT WOUNDS TO-DAY. 

Take out your hand. 

Put it back again. 

Sponge all of the fluid out of the well which 
the hand produces. 

The sponges for this part of the work must 
be held by long sponge-holders. 

Be sure that the sponge passes along the 
palmar side of your hand and into Douglas' 
cul de sac. 

The amount of fluid which can be removed 
from this cul de sac after the abdominal cavity 
is apparently dry is surprising. 

If '' no great man is ever surprised," then no 
great man has ever tried to dry Douglas' pouch 
after an ovariotomy. 

The operative work so far described should 
have taken not more than fifteen minutes for 
its completion. 

Do not hurry in closing the abdominal 
wound. 

The patient will not receive an appreciable 
amount of shock from the further required 
manipulations, and ten minutes spent in closing 
the wound will be time well spent. 

Pass strands of silk-worm-gut transversely 



HOW WE 7'KEAT WOUNDS TO-DAY, 9 1 

across the wound at distances of an inch and 
a half apart. 

Each strand passes through the tissues 
above peritoneum and below muscle, and 
emerges from the skin at points situated 
two or three inches from either margin of 
the wound. 

These strands are to support the abdominal 
walls ; and when the proper time comes they 
are to be fastened as follows : 

Take from the carbolic-acid solution two 
strips of sheet-lead, and proceed according 
to instructions on page 65. 

Each strip is an inch or more in breadth, 
and is nearly as long as the wound. 

Holes have been made throuo^h the lono- 
middle of the strips with an awl at distances 
of half an inch apart. 

Apply one strip first. 

Pass the emerging ends of silk-worm of one 
side of the wound through the corresponding- 
holes in the lead. 

Slip a perforated shot down on each gut to 
the lead. 

Pinch the shot so that it will hold. 



92 HOW WE TREAT WOUNDS TO-DAY. 

An assistant now presses on the sides of the 
abdomen and relaxes the region of the wound. 

The second strip of lead is applied to the 
silk-worm-gut strands on the other side of 
the wound. 

After the shot have been pinched fast, 
the two strips of lead should support the ab- 
dominal wall near the wound so well that no 
tension is exerted on the catgut sutures, all 
strain falling on the silk-w^orm-gut instead. 

The proper time for applying and fastening 
the lead strips is after all other suturing has 
been completed. 

The other suturing should be done as fol- 
lows : 

Unite the cut margins of peritoneum with a 
row of interrupted catgut sutures placed half 
an inch apart. 

Irrigate. 

Bring the muscular or fibrous margins to- 
gether with a row of interrupted sutures of 
chromic catgut placed rather more than half 
an inch apart. 

Be sure that each knot is a square one, and 
that the ends of catgut are not cut too short. 



now WE TREAT WOUNDS TO-DAY. 



93 



Irrigate. 

Suture the skin and adipose tissues with a 
row of interrupted catgut sutures placed more 
than an inch apart, and then put in a con- 
tinued suture for close approximation of skin 
margins. 




THEORETICAL TRANSVERSE SECTION THROUGH ABDOMINAL WALL 
AND DRESSING. 



1. Binder. 

2. Gutta-percha tissue. 

3. Bichloride cotton. 

4. Bichloride gauze, 

5. Lister protective. 



6. Lead plate and shot. 

7. Silk-vvorm-gut sutures. 

8. Catgut suture. 

9. Peritoneum. 

10. Abdominal wall. 



II. Rectus muscle. 



Drainage apparatus is not ordinarily required 
for this wound. 

After tipfhtenino- the silk-worm-out sutures, 
iodoform is to be sprinkled over the ab- 
dominal wound and under the lead strips. 

The gutta-percha tissue, towels, rubber 
sheet, etc., may now be remo\c\l. 



94 ^OW WE TREAT WOUNDS TO-DAY, 

A two-inch wide strip of Lister s protective 
is taken out of its carbolic-acid solution and 
laid over the line of catgut sutures. 

Put a handful of mussed-up gauze over the 
protective and the lead. 

A wad of bichloride cotton two inches thick 
covers the gauze. 

The wad must be large enough to extend 
two or three inches beyond the margins of the 
gauze on all sides. 

Cover the cotton with a foot-square piece of 
gutta-percha tissue, so that the dressing will re- 
main slightly moist for a few days. 

Pass a broad bandage around the abdomen. 

Pin a binder snugly over all. 

Remove the gutta-percha-tissue covering at 
the end of six or seven days. 

Change the dressing for the first time at the 
end of two weeks. 

Remove the lead strips and the silk-worm-gut. 

Apply a handful of bichloride cotton and al- 
low it to remain for a couple of days — until the 
little silk-worm-gut tracks have closed. 

Class i. — Incised Wound, Variety 4, An 
Operative Wound which Remains Exposed. 



HOW WE TREAT WOUNDS TO-DAY, 95 

An internal urethrotomy for a stricture situ- 
ated three inches from the meatus will per- 
haps furnish a good example of this variety of 
wound. 

The bougies, sounds, and urethrotomes 
which are to be used must be cleaned by a 
person who knows what a surgical degree of 
cleanliness means. 

The instruments should lie in an 1-30 car- 
bolic-acid solution for at least half an hour be- 
fore the operation. 

A towel wrung out in 1-1,000 bichloride so- 
lution must be put where needed, for the rest- 
ing of instruments while they are not in use 
during the operation. 

The surgeon's hands and the parts of the 
patient's skin which will be touched must be 
scrubbed with 1-1,000 bichloride solution. 

Half a drachm of a four-per-cent. solution of 
hydrochlorate of cocaine is to be injected into 
the urethra, ten or fifteen minutes before the 
operation. 

The cocaine solution should be rubbed about 
in the urethra so that a large nuicous surface 
will feel its influence. 



96 ffOlV WE TREAT WOUNDS TO-DAY. 

If any vaseline or oil happen to be in the 
urethra when the cocaine is injected, the latter 
will of course be inert. 

After cutting the stricture, the urethra, as 
far back as the triangular ligament, should be 
washed out with 1-2,000 bichloride-of-mercury 
solution. 

The w^ashing may be easily done by attach- 
ing a No. 9 soft catheter to the nozzle of the 
irrigator and then passing the catheter down 
to the triangular ligament. 

When the stop-cock is turned, the irrigating 
solution will run back along the sides of the 
catheter and escape. 

The antiseptic after-treatment of an uncom- 
plicated case of this sort will consist simply of 
the injection of a couple of drachms of a solu- 
tion of iodoform in sweet oil (iodoform 3i., 
sweet oil f. 5 i.) into the urethra, after each pas- 
sage of urine for the following three or four days. 

Sounds to be passed before the wound has 
healed must be lubricated with the above 
iodoform solution. 

If troublesome hemorrhage follow the opera- 
tion it may be stopped in the following way : 



HOW WE TREAT WOUNDS TO-DA V. 97 

Slip a six-inch long bag of thin rubber or 
gold-beaters skin over the end of a hard 
catheter. 

Tie the mouth of the bag closely about the 
catheter with stout thread. 

Dip the apparatus in the iodoform solution 
and pass it into the urethra. 



iSHtoiipE 



APPARATUS FOR CONTROLLING URETHRAL HEMORRHAGE. 

I. Ready for insertion into the urethra. 

3. End of catheter bent and tied, to prevent escape of air after inflation of bag. 

Blow through the catheter, and the bag will 
distend to any desired dimensions. Bend and 
tie the end of the catheter. Fasten the whole 
in place. 

If one bag is not strong enough use two to- 
gether. 

Let out the air when the patient wants to 
use his urethra, and remove the appai'atus. 

Hemorrhage after perineal section, and nasal 
hemorrhage, can be managed with the same 
device. 



98 HOW WE TREAT WOUNDS TO-DAY. 

If a peri-urethral abscess follow the opera-^ 
tion of urethrotomv, there must be no inde- 
cision as to its treatment. 

Go into it at once with scalpel and with 
antiseptic precautions. 

Do not wait to see what will become of it. 

We do not stand by a drill blast until it 
goes off in order to ascertain whether the fuse 
is really burning or not. 

I have seen two deaths from pyaemia as a 
result of waiting to see whether the peri- 
urethral abscess would go off or not. 

I have stood by the bedside of these patients 
while the devastating fever lighted up their 
faces with a lurid glow, or while their teeth 
chattered and clashed together, and their mus- 
cles contracted in horrible spasms, until the 
very windows of the room rattled ; and have 
heard them — clear-minded — beg longingly for 
the relief which could not be given. Know- 
ing, too, that had the operator understood 
antiseptic methods of operating, the poor fel- 
lows might have been enjoying happy days at 
their homes at the time when their pinched 
features and sunken eyes and quivering move- 



HOW WE TREAT WOUNDS TO-DAY. 99 

ments showed that the sands of Hfe had 
nearly run from their cracked and unmended 
glasses. 

Class i. — Incised Wound ; Variety 5, A 
Wound Requiring Frequent Change of 
Dressing. 

The operation for the radical cure of an old 
indolent ulcer of the leg, will bring in a 
wound which requires numerous changes of 
dressing. 

Skin-grafting must be resorted to, and con- 
sequently frequent exposure of the wound will 
occur. 

Here is the way in which an old indolent 
ulcer of the leg is best handled : 

Anaesthetize the patient. 

Shave the leg. 

Wash off soap-suds with a 1-1,000 bichlor- 
ide solution, and scrub with a nail-brush at the 
same time. 

Apply Esmarch's bandage to the limb. 

Cover the foot and ankle with a towel wrung 
out in an 1-1,000 bichloride solution. 

Put another such towel around the leg above 
the ulcer. 



lOO HOW WE TREAT WOUNDS TO-DAY. 

Lay a third disinfected towel on the rubber 
sheet under the leg. 

Scrub your hands in the i-i,ooo solution 
of bichloride of mercury. 

Irrigate with i-i,ooo bichloride solution. 
Cut away the indurated floor and walls of the 
ulcer with the sharp spoon and scalpel. 

Don't stop until periosteum or soft walls are 
reached. 

Soak a small handful of bichloride gauze in 
balsam of Peru. 

Pack the wound with this gauze. Wet a 
handful of bichloride gauze and place it over 
the other gauze. 

Cover all gauze with a handful of bichloride 
cotton. 

Put a sheet of gutta-percha tissue over the 
whole in order to keep the dressing moist. 

Bandage lightly., 

Put the patient in bed. 

Elevate the leg. 

Keep the patient in bed for ten days. 

Keep the leg elevated for ten days. 

Don't change the first dressing until ten days 
have passed. 



HOW WE TREAT WOUNDS TO-DAY, lOI 

Give the patient stimulating diet during the 
confinement in bed. 

Keep on with stimulating diet after the 
patient is out of bed. 

Allow the patient to sit up in an easy chair, 
but insist on continued elevation of the healing 
leg. 

Massage and douching to the other leg will 
improve the circulation in both of them. 

When the first dressing has been removed, 
the condition of the granulations will decide 
what steps are next to be taken. 

If the granulations are not nearly up to the 
surface line, the former kind of dressing must 
be reapplied. 

When the granulating surface and the cu- 
taneous surface are nearly on a level, the treat- 
ment must be changed. 

Wash the granulating surface and the skin 
in its vicinity with warm saturated boric-acid 
solution dripped from a sponge. 

Don't touch the granulations with the sponge. 

Reshave a portion of the skin of the leg. 

From this cleaned surface cut enough pea- 
sized pieces of skin to make a row around the 



I02 HOW WE TREAT WOUNDS TO-DAY, 

circumference of the ulcer, when they are 
placed on the granulating surface, quarter of 
an inch from the surrounding skin margin. 

Don't cut out the grafts with scissors. They 
are crushed by the scissor action. 

Pick up a little fold of skin on the point of 
a sharp needle, and cut it away with a cataract- 
knife. 

Place each little piece of skin directly where 
you want it on the surface of the ulcer. 

Sprinkle iodoform lightly over the ulcer and 
its contained skin-grafts. 

Take a piece of Lister protective out of its 
bottle of carbolic-acid solution, and wash it off 
in warm saturated solution of boric acid. 

This piece of protective is just large enough 
to cover the ulcer, and is smoothly pressed 
down upon it. 

Dress the graft wounds in the same way. 

Cover all with three or four thicknesses of 
bichloride gauze and a handful of bichloride 
cotton. 

Bandage quite firmly. 

Remove the dressing at the end of five days. 

Wash the ulcer with warm saturated solution 
of boric acid squeezed out of a sponge. 



HOW WE TREAT WOUNDS TO-DA V. 103 

Don't let the sponge hit the surface. 

Add a new lot of grafts if there is room for 
them, and dress as before. 

It will seldom be necessary to add more 
than two or three series of grafts. 

Some operators prefer to cover the Avhole 
granulating surface at one sitting with half-inch 
long strips of skin. 

I have seen perfect results after such treat- 
ment, but am. satisfied that the rather slower 
method is the surer one. 

If large strips of skin are to be applied, the 
scar left at the point from which they were 
removed will be noticeable, unless the following 
method is observed. 

Shave and prepare, antiseptically, a space 
several inches long over the anterior aspect of 
the leg. 

Remove a lanceolate-shaped riband of skin, 
which is long enough to contain sufficient 
material for coverino- the ulcer when cut into 
sections for that purpose. 

The wound which is left after the remo\ al 
of a strip of skin of this shape can be so nicely 
closed with catout that the scar will be 



104 ^^OW WE TREAT WOUNDS TO-DAY, 

scarcely apparent when the dressing is re- 
moved a couple of weeks later. 

The usual dressing with iodoform, Lister 
protective, and bichloride gauze should be em- 
ployed. 

Class 2 and Class 3, Lacerated and Con- 
tused Wound ; Variety i, A Wound which is 
Equally Lacerated and Contused. 

Classes 2 and 3 are inseparable. 

The injury which causes a lacerated wound 
must contuse the tissues more or less ; and, 
conversely, the injury which causes a contused 
wound must lacerate the tissues to a certain 
degree. 

Whether a wound shall be called a lacerated 
one or a contused one will depend upon the 
preponderance of one or the other condi- 
tion. 

For variety first, in which the two conditions 
are about equally present in degree, a common 
scalp wound will give a good illustration. 

A man, on alighting from his carriage, 
catches one foot in the wheel and falls, 
striking his head upon the smooth pavement. 

The tissues at the point of impact were so 



HOW WE TREAT WOUNDS TO-DAY, 105 

compressed for the moment between stone 
and bone that they were rendered dense and 
fragile ; and being fragile — broke. 

The wound is two inches long, and looks 
almost as though it were made with a knife. 

The wound extends from the middle line of 
the forehead back into the region of the hair. 

Hemorrhage is profuse. 

The margins of the wound are contused and 
inclined to be oedematous. 

A small flap of pericranium has been torn 
up from the frontal bone. 

Grains of sand and loose hairs have fallen 
in on the exposed tissues. 

As the scalp skin is not very sensitive, this 
patient will not require an anaesthetic. 

Let the patient lay his head on the rubber 
sheet. 

Shave the skin for a distance of at least an 
inch on either side of the wound. 

Wash away soapsuds and blood with 1-1,000 
bichloride-of-mercury solution. 

Wring out a towel in 1-1,000 bichloride so- 
lution, and lay it where it will receive instru- 
ments, etc., which are temporarily not in use. 



I06 HOW WE TREAT WOUNDS TO-DAY, 

Scrub your hands with i-i,ooo bichloride 
solutiorio 

Remove with small forceps every single hair 
which has fallen into the wound. 

Do not allow even half a hair to remain. 
Take out every grain of sand. 

Trim away with a sharp scalpel any irregu- 
lar or ragged bits of skin which would inter- 
fere with close apposition of the sides of the 
wound. 

Sponge with i-i,ooo bichloride solution. 

Control hemorrhage by pressure from time 
to time as you work. 

Fasten the margins of torn pericranium to- 
gether with small catgut. 

For drainage purposes, employ a couple of 
strands of silk-worm-gut, fresh from their 1-30 
carbolic-acid solution. 

Lay these strands in the bottom of the 
wound, and allow them to project from its 
lower angle. 

Suture the scalp margins smoothly and even- 
ly together with interrupted catgut sutures, 
but do not tie the sutures until a few moments' 
pressure has stopped all bleeding. 



now JVE TREAT WOUNDS TO-DAY, 107 

Sprinkle iodoform along the line of suture. 
Take a half-inch wide strip of Lister protec- 
tive out of its bottle of 1--30 carbolic-acid so- 
lution, and cover the wound line with it. 

Lay a generous handful of gauze over the 
protective. 

Cover all with a sufficiently large piece of 
gutta-percha tissue. 

Bandage the dressing snugly in place. Re- 
move the dressing seventy-two hours later. 

Take out the catgut and the silk-worm-gut. 
Place a small dressing of gauze over the place 
where the wound was. 

Leave the dressing in place for forty-eight 
hours. 

I have treated wounds like the above de- 
scribed in children, in the middle-aged, and in 
the aged ; in drunkards, invalids, and in tramps ; 
and have never yet failed to get primary union 
when the wound was treated within ten hours 
after the injury. 

Even when the skull had been fractured, the 
scalp wounds, treated properly, healed b\' pri- 
mary union. 

Compound and simple fractures are practi- 



Io8 HOW WE TREAT WOUNDS TO-DAY. 

cally one and the same thing to the patient 
if he receive scientific antiseptic treatment in 
time. 

Several years ago I happened to be in the 
position to see a large number of scalp wounds 
daily, and the effect of the different methods 
of treatment which they presented was of 
startling interest. 

Some cases came to us with ordinary silk 
sutures in the wound, while hair and dirt re- 
mained beneath the surface. 

Cases which were always in bad shape were 
the ones which had been treated openly and 
decorated with dried and hard dressings which 
stuck fast. 

Many scalp wounds had been closed tightly^ 
with no provision for drainage. 

Others had been filled with some astringent 
iron-salt solution at the drug-store ; the person 
who applied it having learned how to stop 
hemorrhage. 

Tight bandaging over pretty good dress- 
ings had frequently started a dangerous cel- 
lulitis. 

By far the worst of all were the cases in 



HOPV WE TREAT WOUNDS TO-DAY. IO9 

which the wounds had been closed with strips 
of adhesive plaster. 

The margins of the wound had dried and 
adhered. 

Serum was backed up in the deeper parts of 
the wound. 

Antiseptic precautions had been omitted. 

The wound was in a dangerous condition. 

The physician never expects to injure the 
patient when he applies an unscientific dressing. 

The man who is run over in the street by a 
carriage, never expects to be run over when 
he starts to cross the street. Men are run over 
in the street, however. 

Patients' lives are really put in jeopardy by 
bad dressing of wounds. 

A good many of us have seen men die be- 
cause they were not properly treated surgi- 
cally. 

It is cruel to close a scalp Avound with ad- 
hesive plaster, and allow the patient to go 
about with no additional dressing. 

A dozen small plastered scalp wounds may 
do well. 

How about the thirteenth case ? 



1 10 HOW WE TEE A T WOUNDS TO-DA K 

Develops cellulitis ! 

Is cellulitis necessary ? 

Not at all ! It is superfluous. Especially if 
it occur in your own family. 

If you are inclined to put plaster on a scalp 
wound — 

Don't do it ! 

Withhold the microbe. 

In no line of surgery is it easier to bungle a 
job than in treating the trivial wounds known 
as scalp wounds. 

Treatment for the cerebral symptoms which 
accompany some scalp wounds requires no 
special consideration in these pages. 

Classes 2 and 3, Lacerated and Contused 
Wound ; Variety 2, An Inflamed Wound. 

Suppose that the wound described under 
Variety i comes to you for the first time three 
days after the date of injury. 

Some one has closed the wound tightly with 
silk sutures. 

A compress moistened with carbolic-acid 
solution was placed over the wound, and the 
patient was told to keep this compress moist 
with the carbolic-acid solution. 



HO W WE TREA T WOUNDS TO-DA F. Ill 

The patient, as usual, failed to carry out 
directions. 

The margins of the wound look puffy and 
red, and considerable constitutional disturb- 
ance exists. 

On removing the silk sutures, and separat- 
ing the margins of the wound, a drachm of 
''wrong-looking" discharge runs out. 

Local treatment must be as follows : 

Trim away hair from the margins of the 
wound with the razor. 

Wash out the wound thoroughly with i-i,ooo 
bichloride-of-mercury solution. 

Sprinkle iodoform over the exposed surface. 
Lay a strip of disinfected Lister protective 
over the wound. 

Moisten a handful of bichloride gauze in 
i-i,ooo bichloride solution. 

Squeeze the gauze as dry as possible. 

Apply this dressing over the wound, and 
cover it with gutta-percha tissue. 

Bandage lightly. 

Chano^e the dressinq- once a week, and re- 
dress in the same way. 

The wound will granulate nicch' sc^ soon as 
proper treatment begins. 



112 HOW WE TREAT WOUNDS TO-DAY, 

Classes 2 and 3, Lacerated and Contused 
Wound ; Variety 3, A Wound with Prepon- 
derance of Laceration. 

The patient has had his leg under a car- 
wheel, and has suffered a compound fracture 
of the tibia and fibula, at a point midway be- 
tween the knee and the ankle. 

The muscles and skin are badly lacerated 
and contused. 

A two-inch-long hole in the skin has been pro- 
duced by the sharp upper fragment of the tibia. 

The anterior and posterior tibial arteries are 
torn at the seat of the wound. 

Pressure with the finger on a toe-nail shows 
by the departure of blood from the underlying 
capillaries, and the return of the blood on re- 
moval of the finger, that circulation of blood 
still continues in the foot. 

If the patient has lost so much blood that 
an immediate operation would be dangerous, 
then hot bottles about the legs and arms, aro- 
, matic spirits of ammonia internally, and brandy 
hypodermically, may be supplemented by in- 
jecting slowly into the radial artery, or into a 
large vein, several ounces of Schwartz' solu- 



HOW WE TREA T WOUNDS TO-DA V. I 13 

tion (T^ Aquae Oj, sodii chloridi 3i., liquoris 
potassse gtt. li.). 

When the heart beats regularly and strongly, 
proceed with the operation. 

We suppose that a tourniquet has been ap- 
plied to the femoral artery, and that iodoform 
has been thrown on the wound, before begin- 
ning the restorative measures. 

If the patient suffer from shock alone, and 
not from hemorrhage, I should have no hesi- 
tation, as a general thing, in proceeding at 
once to operate. 

The patient's heart will usually become 
•stronger in its action so soon as the full 
effects of ether are felt, and the condition of 
shock does not often remain for any length 
of time after the operation has been completed 
in a case like the one under consideration. 

Get the following things in shape for the 
operation : 

Rubber sheet. 

Irrigator filled with t-2,ooo bichloride so- 
lution. 

Washbowl filled with 1-2,000 bichloride 
solution for washing sponges. 



114 HOW WE TREAT WOUNDS TO-DAY, 

Bowl of i-i,ooo bichloride solution for the 
hands of the operator and assistants, for the 
patient's skin, and for wetting the towels. 

Dish filled with 1-30 carbolic-acid solution 
for large instruments. 

Dish filled with 1-30 carbolic-acid solution 
for small instruments. 

Wide-mouthed bottle filled with catgut in 
alcohol ; wide-mouthed bottle of Lister pro- 
tective in 1-30 carbolic-acid solution. 

Silver wire or silk-worm-gut in 1-30 carbolic- 
acid solution. 

Iodoform. 

Bichloride gauze. 

Bichloride cotton. 

Rubber drainage-tubes in 1-30 carbolic-acid 
solution. 

Razor and nail-brush. 

Plaster of Paris bandages. 

Bichloride-of-mercury gauze bandages. 

Plain bandages. 

Towels. 

Suspension apparatus described on page 
112. 

Anaesthetize the patient. 



HOW WE TREA T WOUNDS TO-DA K. 115 

See that the tourniquet or elastic bandages 
are all right. 

Put the rubber sheet under the leg. 

Shave the leg from the knee to the ankle. 

Wash away soapsuds and blood with i-i,ooo 
bichloride solution, and scrub the leg with the 
, nail-brush at the same time. 

Wring out towels in i-i,ooo bichloride solu- 
ticn, and place them under the leg ; around the 
leg, above and below the injured part ; and on 
the table where instruments are to be laid. 

All hands which are to touch the wound or 
the dressings must be scrubbed in i-i,ooo bi- 
chloride solution. 

Open the wound so freely with a large scal- 
pel that the injured tissues may be dealt 
with. 

Be careful not to have too small an opening. 

Irrigate with the 1-2,000 bichloride solu- 
tion pretty constantly during the operation. 

Make a very free counter-opening over the 
fractured part of the fibula. 

Be cautious about the size of this opening, 
and not have it too small. 

Trim away all muscular and other soft ris- 



Il6 HOW WE TREAT WOUAWS TO-DAY. 

sues which are so crushed and lacerated that 
they cannot Hve. 

Cut away rough or loose margins and points 
of bone, and remove separated fragments. 

Shape the remaining fragments so that they 
will fit together as well as possible. 

Drill holes in the ends of the fragments, so 
that they can be fastened together with silver 
wire (or with silk-worm-gut). 

Take the wires out of the carbolic-acid solu- 
tion, and fasten the bones together with them 
in such a way that surrounding tissues will not 
be irritated by their presence. 

These bone sutures are not to be removed, 
but are to be carried about by the patient after 
he is well. 

If divided large nerves are found, suture 
their trimmed ends together with small catgut 

Ligate arteries with No. 7 catgut. 

Unite muscular tissues with catgut sutures. 
If ends of a divided muscle cannot be brought 
together, an approximation to this condition 
can be made by means of long sutures, and the 
space between the ends will fill with new tissue 
later, thus preserving the identity of the muscle. 



HOW WE TREAT WOUNDS TO-DAY, II J 

I have seen a space of at least two inches 
filled in in this way, although at the time of 
operation several spectators were afraid that 
" aiming the ends of a muscle at each other " 
from such a distance would be of no avail. 

Dry the wound with a sponge or give it a 
final washing with 1-5,000 bichloride solution. 

Put two large-calibre rubber drainage-tubes 
where they will best act as drainers. 

Bring cutaneous margins loosely together 
with catgut sutures. 

Powder iodoform over the wound. 

Put Lister protective over all exposed parts 
o{ the wound and along the lines of suture. 

Wring out a couple of handfuls of bichloride 
gauze in an 1-2,000 bichloride solution and 
apply about the wound. 

Fasten the dressing loosely in place with a 
bichloride gauze bandage. 

Serum will run through slightly moist gauze 
much better than through dry gauze, but wet 
gauze might excite suppuration, and suppura- 
tion is to be avoidecl in this wound. 

Wind five yards of bichloride gauze about 
the leg between the knee and the ankle. 



Ii8 



HO IV WE TREAT WOUNDS TO-DAY, 



Bandage the gauze lightly in place with a 
bandage of the same material. 

Put a two-inch thick layer of bichloride 
cotton around the gauze from the knee to the 
ankle. 




THEORETICAL SECTION THROUGH LEG AND DRESSING AT A POINT 
SITUATED NEAR THE FRACTURE. 



1. Ordinary bandage. 

2. Plaster-of-Paris splint. 

3. Bichloride cotton. 

4. Bichloride gauze. 



5. Lister protective. 

6. Safety-pin. 

7. Drainage-tube. 

8. Leg. 



Apply an anterior plaster of Paris splint, 
and bandage it in place. 

Make the splint by running wet plaster of 
Paris bandages up and down on the anterior 
aspect of the dressing, until a sufficient thick- 
ness for holding the leg firmly has been 
applied. 



HO W WE TREA T WOUNDS TO- DA V. 1 19 

Sling the leg by means of broad bandages 
from a bar above the bed. 

The higher the leg is elevated, the more 
comfortable will the patient be. 

After a week has passed the dressing must 
be changed for the purpose of removing the 
drainage-tubes. 

Do the changing under irrigation with 
1-1,000 bichloride-of-mercury solution. 

Prepare your hands as carefully as for a 
fresh wound. 

Remove the rubber drainage-tubes. 

Insert absorbable bone-drains in their place. 

Sprinkle more iodoform about the wound. 

Apply Lister protective and the rest of the 
dressing in the same manner as when the leg 
was first dressed. 

If one of the new drainage-tubes happen to 
hit the edge of the bed while being handed to 
the surgeon, it must go back into its bottle, and 
another one must be used in its place, — just as 
with the previously inserted rubber tubes. 

If a safety-pin for the tube be touched b\' an 
assistant whose hands are unprepared that 
safety-pin must be discarded. 



I20 HOW WE TREAT WOUNDS TO-DAY. 

If a bit of the new dressing is touched by 
unprepared hands, that bit of dressing must not 
be used for the leg. 

Sophists Avho reason out the absurdity of 
these details have suppuration in the cases of 
compound fracture of the tibia and fibula 
which they treat. 

Suppuration should not occur in these cases 
so often as suppuration after simple fracture. 

Surgical sophists do much harm to the cause 
of antiseptic surgery, because their conclusions 
seem very plausible to persons who have had no 
practical experience with scientific antisepsis. 

After the leg has been redressed, it should 
be again elevated as before. 

Keep the patient in bed for six weeks more^ 
and do not change the dressing until six weeks 
have passed. 

The patient can sit up in bed during this 
time, and can read and smoke, and carry on 
business conversations, or enjoy social chats 
with companions, just as though his leg were 
not broken. 

When the dressing is removed, the character 
of the union at the point of fracture will deter- 



HO W WE TREA T IVO UNDS TO-DA V. 121 

mine what protection in the way of a sphnt is 
needed. 

Hot and cold douching, massage, and passive 
joint motion will be required after removal 
of the dressing. 

Such a case will have run a very different 
course from the cases of this sort which most 
of us heard about when we studied medicine 
at college. 

We were then taught to dread the danger 
from pyaemia, septicaemia, erysipelas, exhaust- 
ing suppuration, and non-union. 

Now we have only the non-union to fear, 
and when suppuration is avoided, this accident 
must obviously occur much less frequently than 
formerly. 

The discharge which is found in a six-weeks'- 
old dressing will be gelatinous in consistency, 
and under the microscope will be found to 
contain a large amount of granular debris and 
a small proportion of pus corpuscles. 

In connection with this sort of case, I wish 
to make objection to the method of working 
for primary occlusion in cases where the open- 
ing in the skin is small. 



122 HOW WE TREAT WOUNDS TO-DAY. 

It is unfortunate that any one discovered 
that primary occlusion in compound fractures 
would give good results. 

A large proportion of these cases in question 
go remarkably well. 

I have treated several cases by this method, 
and in all of them the healing course was 
eminently satisfactory. 

But! 

Sometimes these cases do not do well. 

When they do not do well, they do very, 
very badly. 

They assume a septic condition of some 
sort. 

This septic condition cannot occur in a 
recent compound fracture which has been 
treated by the method of opening up the 
wound and managing the injured tissues with 
scientific antiseptic precautions. 

The surgeon will have no anxiety for the 
welfare of the patient after this has been 
done. 

He will not have to wait and see what the 
wound will do. 

He knows just what it will do. 



HOW IV E TREAT WOUNDS TO-DAY. 1 23 

Classes 2 and 3, Lacerated and Contused 
Wound ; Variety 4, A Gunshot Wound. 

A man's arm is struck by a Number 32 
bullet, fired from a revolver at close range. 

The bullet crushes the external condyle of 
the humerus, tears away part of the shaft of 
the humerus, and breaking into a dozen pieces 
remains imbedded in the bone. 

The synovial cavity at the elbow is opened 
by a small fissure. 

The nearest doctor has been called in, and 
has introduced through the hole in the skin 
about every thing which would enter it, from 
his silver probe to his catheter, and forceps of 
every sort. 

He will wish that he had a Nelaton's probe in 
order to locate the bullet, that he may pull it out. 

In these cases it is not necessary to in- 
troduce even a clean silver probe before an;^s- 
thetizing the patient. 

The wound to be decently treated must be 
well opened any way, and then is the proper 
time for examining the wound. 

Make the usual preparations for doing an 
antiseptic operation. 



124 ^OJV WE TREAT WOUNDS TO-DAY, 

Put the patient under the influence of ethen 

Apply Esmarch's bandage to the injured arm. 

Put the rubber sheet in place. 

Shave the arm about the elbow, and several 
inches above and below it. 

Wash away soapsuds and blood with i-i,ooo 
bichloride-of-mercury solution. 

Wring out four towels in i-i,ooo bichloride 
solution. 

Wrap one of them about the arm above the 
elbow. Put another one about the arm below 
the elbow. Lay one towel under the elbow on 
the rubber sheet. 

Spread the last one out on the operating- 
table and put instruments, etc., on it when 
they are laid aside for a moment during the 
operation. 

All parties who are to touch the wound or 
the instruments or the dressings must scrub 
their hands in i-i,ooo bichloride solution. 

Irrigate during the operation with 1-2,000 
bichloride solution. 

Take the probe out of the dish of carbolic- 
acid solution and determine to some extent 
the nature of the injury to the bone. 



HO IV WE TREAT WOUNDS TO-DAY. 1 25 

Make a cut which includes the bullet hole in 
the skin, and which is long enough to allow of 
examination and treatment of the shattered 
portion of the humerus. 

Trim away destroyed soft tissue in the track 
of the bullet. 

Pull out the small fragments of bone and of 
bullet. 

Chisel off rough margins and points of 
bone. 

It will not be necessary to open the synovial 
cavity widely and wash it out unless inflamma- 
tory processes have developed in the wound 
previous to the operation. 

Ligate large blood-vessels with No. 7 catgut. 

Remove the Esmarch's bandage. 

Ligate small bleeding vessels with No. 8 
catgut. 

Stop all oozing of blood. 

If oozing can not be easily stopped, insert 
the catgut sutures ready for closing the wound, 
but do not close it. 

Pack the wound with one or two large 
sponges. 

Hold the sponges in place for twenty 



126 HOW WE TREAT WOUNDS TO-DAY. 

minutes or longer with a bichloride gauze 
bandage. 

Remove the bandage and the sponges. 

Lay a bone drainage-tube along the bottom 
of the wound. 

Tie the catgut sutures which are already 
inserted. 

Add a few more superficial ones, if necessary. 

Sprinkle iodoform over the region of the 
wound. 

Lay a strip of Lister proctective along the 
line of sutures, and tear a hole in it opposite 
the emerging drainage-tube end. 

Envelop the elbow in loose bichloride 
gauze, and about the gauze wrap a generous 
supply of bichloride cotton. 

Put the elbow in a right-angled position be- 
fore applying the dressings. Hold it there 
afterward with a piece of card-board, which is 
cut as a right-angled splint, and bandaged on 
the outside of the dressing. 

Sling the arm from the neck and put a 
bandage about the arm and chest. 

Do not keep the patient in bed. 

Remove the first dressing at the end of the 



HOW WE TREAT WOUNDS TO-DAY, \2J 

third week, and then begin passive motion at 
the joint if it is stiff. 

In gunshot wounds, involving soft parts 
alone — not injuring abdominal contents, — 
and which are presumably free from pieces of 
clothing or of wadding, I believe the best 
routine treatment to consist in a simple anti- 
septic dressing of the cutaneous perforations 
with iodoform, bichloride gauze, and gutta- 
percha tissue ; a couple of strands of catgut 
being inserted for a short distance into each 
bullet hole, in order to allow of free escape of 
serum. Absolute rest must be insisted upon. 

Where bone is fractured by a bullet, the 
only rational treatment is similar to that 
described above in connection with the bullet 
in the humerus. 

Class 4, Punctured Wound; Variety i, A 
Penetrating Wound of the Knee-joint. 

A knife blade has been thrust into the knee- 
joint, and the patient applies for surgical help 
shortly afterward. 

Put the patient on the tabic. 

Spread the rubber sheet under the injured 
limb. 



128 HO IV WE TREAT WOUNDS TO-DAY, 

Wash the skin in the vicinity of the wound 
very gently with i-i,ooo bichloride-of-mercury 
solution. 

Stick a couple of strands of catgut between 
the margins of the wound — just deeply enough 
to allow serum to come to the surface. 

Sprinkle iodoform over the wound. 

Put a litttle piece of Lister protective over 
the cut. 

Apply a few layers of moistened bichloride 
gauze, and over this a handful of dry bichloride 
gauze. 

Cover all with gutta-percha tissue, so that 
effusions from the wound will not dry and 
close the opening in the skin. 

Immobilize the joint. 

Be certain that the whole knee is put in a 
state of rest. 

The slightest amount of movement is haz- 
ardous. If no inflammatory symptoms occur, 
the dressing may be changed forty-eight hours 
later and the catgut removed. 

Replace the rest of the dressing, and keep 
the knee quiet for three or four days longer. 

If in spite of the above-described precau- 



HOW WE TREAT WOUNDS TO-DAY. T29 

tions, the deep parts become inflamed and the 
joint is swollen, hot, and red with symptoms 
•of synovitis, there is just one thing to be 
done. 

Don't call a consultation ; because some one 
may want to wait a little while. 

Don't ask any one's advice, but tell your 
assistants what is going to be done. 

Anaesthetize the patient. 

Apply the tourniquet to the femoral artery. 
Shave the skin about the entire knee. Wash 
off soapsuds with i-i,ooo bichloride-of-mer- 
€ury solution, and scrub the skin with a nail- 
brush at the same time. 

Wring out towels in i-i,ooo bichloride so- 
lution. Place one of them on the rubber 
sheet under the knee. 

Wrap one of them about the leg above the 
knee, and another one about the leg beloAv the 
knee. 

Hands are prepared as usual with i-i,ooo 
bichloride-of-mercury solution. 

The irrigator is filled with i-i,ooo bichlo- 
ride solution. 

Make a two-inch-long opening Into the joint 



130 HOW WE TREAT WOUNDS TO-DAY, 

in such a way as to include the knife wound in 
the scalpel cut. 

Make a counter opening into the joint at a 
point situated just above and external to the 
attachment of the biceps tendon. 

Ask one of the assistants to scrub the nozzle 
of the irrigator with 1-1,000 bichloride solution. 

Put the nozzle of the irrigator into one of 
the openings in the joint, and wash the inte- 
rior of the joint thoroughly. 

To wash the joint thoroughly the synovial 
cavity must be distended to its fullest extent 
several times in rapid succession with the anti- 
septic solution, and each time that it is dis- 
tended the knee should be vigorously rubbed, 
flexed, and extended. 

After washing the joint for a few minutes 
with the 1-1,000 solution, the irrigator should 
be filled with 1-5,000 bichloride solution, and 
several flushings given with the latter. Some 
of the solution will remain in the joint, and 
the 1-1,000 solution is rather too strong to 
leave there with safety. 

Put a rubber drainage-tube in each of the 
openings into the joint. 



HOW WE TREAT WOUNDS TO-DAY, I3I 

Fasten a safety-pin in the emerging margin 
of each tube. 

Suture the cutaneous wounds. 

Sprinkle iodoform about the wounds. 

Apply a couple of strips of Lister protec- 
tive, and cut holes in the protective opposite 
the drainage-tube openings. 

Envelop the knee in several handfuls of bi- 
chloride gauze. 

Bandage a large wad of bichloride cotton 
around the gauze. 

Put a splint along either side of the leg over 
the dressings, and immobilize the joint. 

Elevate the leg. 

Change the dressing a week later for the 
purpose of removing the drainage-tubes. 

Apply a smaller but similar dressing. 

Remove the latter ten days later. 

If any one object to the operation as adding 
more danger to the patient's condition, that 
person has had no surgical experience — at least 
not what we call surgical experience to-da\-. 

Class 4, Punctured Wounds ; A^arict)' 2, A 
Deep Palmar \\\:)und. 

A very common woimd is the one caused In* 



132 ROW WE TREAT WOUNDS TO-DAY. 

thrusting a large splinter of wood, or some 
other rough-pointed object, into the thenar em- 
inence, or into the tissues between the meta- 
carpal bones of the thumb and index-finger. 

Tetanus or cellulitis is particularly apt to 
follow these wounds. 

The reason is, perhaps, because the muscu- 
lar and fibrous planes bear such a relation to 
each other in the way of position, that dis- 
charges from the deep parts of the wound 
find difficulty in escaping ; and because the pe- 
culiarly exciting effect of inflammation in dense 
fibrous tissue like palmar fascia produces a 
particularly deep impression, on account of the 
close proximity of the man}^ nerves which be- 
long to the hand. 

The hand and the foot are structurally ho- 
mologous, and their wounds are in ways in- 
flammatory, analogous. 

We may suppose, then, that the certain 
growth in the wound of various and specific 
micro-organisms, in association with a co-exist- 
ing non-resisting condition of the ordinarily 
repellant nerves, produces the disaster of teta- 
•nus or cellulitis. 



HOW WE TREAT WOUNDS TO-DA Y. 133 

Both of the diseases in question are avoided 
if the patient be properly treated shortly after 
the wound has been made. 

Proper treatment is as follows : 

Apply Esmarch's bandage to the arm above 
the injured hand. 

Place the hand on a part of the rubber sheet. 
Scrub the hand with i-i,ooo bichloride solu- 
tion. 

Wring out a towel in i-i,ooo bichloride so- 
lution. 

Put the towel on the rubber sheet under the 
hand. 

Scrub your own hands in i-i,ooo bichloride 
solution. 

Open the wound freely enough to allow of 
removal of any foreign body, and to admit of 
easy ligation of blood-vessels, or of insertion 
of drainage apparatus. 

If the wounding splinter have penetrated 
nearly to the dorsum of the hand, it is better 
to complete the perforation with a scalpel. 

Send a stream of 1-2,000 bichloride solution 
throucrh the wound. 

o 

Swell half a dozen strands oi catgut in a 
saucer of 1-2,000 bichloride solution. 



134 ^OW WE TREAT WOUNDS TO-DAY, 

Pass the strands into or through the wound 
for purposes of drainage. 

Sprinkle iodoform where it is needed. 

Do not close the wound. 

Lay Lister protective on the skin-wound or 
wounds. 

Wrap loose bichloride gauze about the 
hand. 

Add bichloride cotton over the gauze. 

Bandage firmly enough to keep the hand at 
rest. 

Suspend the arm in a sling from the neck. 

Remove the dressing twelve or fourteen 
days later. Almost no sign of the wound 
should remain at that time. 

Class 4, Punctured Wound ; Variety 3, An 
Inflamed Wound. 

The wound described under Variety 2 has 
been treated without antiseptic precautions. 

You see it for the first time when signs of 
active inflammation have developed. 

The treatment should be the same ' as 
though it were a fresh wound, with three ex- 
ceptions : 

First exception — Wash the depths of the 



HOW WE TREA T WOUNDS TO-DA V. 1 35 

wound very thoroughly with i-i,ooo bichloride 
solution. 

Second exception — Wet the gauze part of 
the dressing before applying it, and cover 
with gutta-percha tissue, so that it will remain 
wet. 

Third exception — Exchange the wet dress- 
ing forty-eight hours later for a dry one. 

The repeated sighs of relief which the pa- 
tient will give after his hand has been properly 
dressed are always striking. 

Class 5, Poisoned Wound; Variety i, Dog 
Bite. 

Canines, when in an aggressive mood, add a 
vigorous shake to their bite. 

If the teeth enter the soft tissues of an ani- 
mal, the contusion which follows the shaking 
is often very extensive. 

This is why dog bites are especially painful, 
and why badly treated cases cause so much 
misfortune. 

A rabid dog seizes a child by the upper 
arm, and the teeth penetrate the muscles. 

Anaesthetize the patient. 

Put the rubber sheet in [)lace. 



136 HOW WE TREAT WOUNDS TO-DAY. 

Shave the skin of the whole upper arm. 

Wash the skin with 1-1,000 bichloride so- 
lution. 

Wring out a towel in 1-1,000 bichloride 
solution, and spread it on the rubber sheet 
under the arm. 

Lay another similar towel on the table^ 
where instruments are to be laid when they 
are out of the dishes of carbolic-acid solution 
and are not in use. 

Prepare your hands as usual. 

Make a free incision through the skin, in the 
vicinity of each tooth hole, and include this 
tooth mark in the cut. 

Continue the incision down through the 
muscular tissue until the deepest contused 
point is laid open. 

Put a couple of quarts of 1-500 bichloride 
solution in the irrigator, and wash the wounds 
for ten minutes with it. 

Bichloride solution of this strength must not 
be left in the wound. 

Pour a couple of quarts of 1-5,000 bichloride 
solution slowly over the wounded tissues, and 
rub them gently with your finger, in order that 



HOW WE TREAT WOUNDS TO-DAY, I 37 

the strong bichloride solution may be carried 
away. 

Sprinkle a very thin layer of iodoform over 
the exposed surfaces, and then tuck a small 
strip of Lister protective into each Avound, in 
order to prevent primary union. 

Wind several layers of bichloride gauze 
loosely about the arm. 

Cover the gauze with a two-inch-thick layer 
of bichloride cotton. 

Bandage the whole arm to the chest to pre- 
vent motion. 

Change the dressing under irrigation with 
1-5,000 bichloride solution five days later. 

Remove the Lister protective. 

Sprinkle a small amount of iodoform over 
the wounds again. 

Place strips of Lister protective over the 
wounds and not in them. 

Apply the gauze and cotton dressing, and 
bandage the arm to the chest as before. 

Do not change this second dressing until 
you believe the wound to be healed. 

The incisions will have exposed the poisoned 
parts of the wound. 



T38 HOW WE TREAT WOUNDS TO-DAY, 

The strong bichloride solution will undoubt- 
edly have destroyed the microbes from the 
dog's teeth. 

Serum from the contused tissues will have 
escaped externally, instead of infiltrating the 
connective tissues and causing swelling and 
pain. 

The operation will have been done anti- 
septically, and healing will go on under one 
dressing with great rapidity. 

Class 5, Poisoned Wound ; Variety 2, Snake 
Bite. 

While hunting with a friend the latter is 
bitten in the leg by a rattlesnake. 

Don't stop to kill the snake. 

Tear open the breeches leg. 

Fasten a handkerchief or strap about the 
leg above the wound so firmly that venous cir- 
culation will be impeded. 

It will be hard to tie the improvised tourni- 
quet tightly enough ; so it will be best to tie 
it very loosely, and then twist it tightly in the 
common way with a stick. 

Open the one or two holes made by the 



IIOM^ WE TREAT WOUNDS TO-DAY. 1 39 

snake's fangs with your knife, and open them 
so widely that the whole depth of the wound 
is exposed. 

The small wounds made by the other teeth 
of the snake are harmless and need receive no 
attention. 

Allow six or eight ounces of blood to escape 
from the knife cut, if so much as that will run 
out, and, at the same time, rub the wound with 
your finger in order to dislodge any of the 
tenacious albuminous poison which remains. 

Remove the tourniquet. 

Wash the wound out with whiskey if you 
happen to have it with you. 

Stop hemorrhage by tying a wad of crushed 
leaves in the wound with the handkerchief 
passed around the leg at that point. 

Get to a place where you can wash the wound 
out with 1-500 bichloride-of-mercury solution, 
and dress it antiseptically. 

Do not poison the patient with unreasonably 
large doses of whiskey given internally. 

I have seen whiskey cause much more 
damage to a patient than the rattlesnake bite 
for which it was ^iven caused. 



I40 HOW WE TREAT WOUNDS TO-DA Y. 

If a layman who knew nothing of anatomy 
wished to treat a snake bite in the way de- 
scribed above, he should make the cut by 
passing the tip of the knife blade down into 
the wound and cutting out, instead of cutting 
directly down as a surgeon would do. 

He should also make the cut in the long 
axis of the limb, in order to avoid cutting 
large blood-vessels. 

He must remember that hemorrhage from 
any bleeding vessel can always be stopped by 
putting a finger directly upon that vessel, and 
that plenty of time will then be given for think- 
ing of a better method for applying the pressure. 

A solution of one grain of corrosive subli- 
mate in two teaspoonfuls of water, injected 
forcibly into a freshly-made fang wound with a 
small syringe, would unquestionably destroy all 
of the snake poison in the wound, and obviate 
the necessity for the crude surgery just re- 
ferred to. 

Three or four syringefuls of the solution 
may be thrown in succession into each fang 
wound, which should be syringed out five min- 
utes later with pure water. 



HOW WE TREAT WOUNDS TO-DAY, 141 

White of ^%%, which is chemically very much 
like snake poison, is instantly coagulated in the 
presence of strong corrosive-sublimate solution. 

Class 6, Burned Wounds. 

Dupuytren classifies burns in six degrees. 

His burn of the first degree presents a 
hyperaemia of the skin, with no exposure to the 
air of tissues beneath the cuticle. 

This burn is not a wound, of course, any 
more than a non-penetrating dog bite is a 
wound. 

Burns of all other degrees, which expose the 
tissues beneath the cuticle to the air, are theo- 
retically and practically wounds in all of their 
attributes. 

Class 6, Burned Wound; Variety i, A 
Limited Burn of the Second Deo^ree. 

A child upsets the teakettle and burns the 
right leg from the knee to the ankle with hot 
water. 

Large blebs and vesicles are raised above 
the surrounding skin, and where the cuticle 
over a bleb has ruptured, the underlying true 
skin is exposed. 



142 HOW WE TREAT WOUNDS TO-DAY, 

Several square inches of true skin have been 
exposed in this way. 

In order to do thorough work it will be best 
to anaesthetize the child. 

This having been done, the little patient is 
placed upon the rubber sheet on the table. 

The skin in the vicinity of the burned region 
is shaved. 

Towels wrung out in i-i,ooo bichloride so- 
lution are spread on the rubber sheet under 
the limb and are wrapped about the thigh and 
foot. 

Your hands having been scrubbed in i-i,ooo 
bichloride solution, a pair of scissors and a 
pair of thumb forceps are taken out of the 
dish of carbolic-acid solution at your side, 
and while an assistant irrigates with 1-2,000 
bichloride solution, strip and pull away all 
loose cuticle and all of the cuticle which covers 
the unruptured blebs. 

This having been done, the towels are re- 
placed by fresh ones, and you proceed to rinse 
the leg thoroughly with 1-5,000 bichloride 
solution. 

Take two-inch-wide strips of Lister protective 



HOW WE TREAT WOUNDS TO-DAY. 1 43 

out of the bottle of carbolic-acid solution 
and rinse them off in 1-5,000 bichloride so- 
lution. 

Lay them smoothly over the wounds in such 
a way that all exposed surface will be covered 
as though with a new skin of the pretty green 
silk. 

Sprinkle iodoform along all margins of 
protective. 

Wrap bichloride gauze smoothly about the 
limb to the thickness of one inch. 

See that the gauze extends beyond the distal 
and proximal limits of the protective. 

Cover the gauze with a two-inch-thick layer 
of bichloride cotton. 

Bandage snugly. 

Elevate the limb on pillows. 

Sprinkle iodoform on damp places in the 
dressinor if serum run throuorh, and add an ex- 
tra wad of bichloride cotton. 

After seven or eight days have passcLl. cut 
open one end of the dressing and sec it all 
is well. 

I have never seen a burn c^t the abo\'c 
character, treated in the manner described, 



144 now IVE TREAT WOUNDS TO-DAY. 

which failed to heal completely under one 
dressing by the tenth day. 

Two cases were already suppurating when 
they came for treatment, but the suppuration 
did not continue after the scientific dressing 
was applied. 

The reasoning through which the scientific 
method for dressing the burn is deduced, is as 
follows : 

1. The condition of anaesthesia protects 
against the shock and irritation which would 
otherwise follow surgical disturbance of the 
wound. 

Further, if an anaesthetic were not given, the 
child's cries would excite a badly timed sym- 
pathy — and bungling work would result. 

2. The antiseptically prepared instruments, 
hands, and surroundings add no active mi- 
crobes to the wound. 

3. Shaving the healthy skin in the vicinity 
of the burn removes microbes, which would 
quickly enter the land of milk and honey 
if they were allowed to remain within sight 
of it. 

4. Removing separated cuticle, which must 



HOW WE TREAT WOUNDS TO-DAY, 145 

decompose after offering temporary protection, 
enables us to reach every part of the wound 
with 1-2,000 bichloride solution. 

The 1-2,000 bichloride solution washes 
away microbe food and destroys microbes. 

5. The final washing with 1-5,000 bichlo- 
ride solution carries away the strong 1-2,000 
solution, which might irritate later. 

6. The Lister protective prevents all exter- 
nal irritation of the wound. 

Exuded serum easily runs out of it into the 
waiting gauze. 

The epithelium cells shoot along under the 
protective without interruption. 

7. The iodoform, and the bichloride of mer- 
cury in the gauze and cotton, offer objection 
to microbe growth in the serum. 

The gauze and cotton are principally useful 
as absorbers of serum and as holders of the bi- 
chloride of mercury. 

Class 6, Burned Wound; X'ariety 2, An 
Extensive Burn of the Second Degree. 

Extensive burns of the second degree often 
occur after steam explosions. 

Large surfaces of cuticle are destroyed, and 



146 NO IV WE TREAT WOUNDS TO-DAY. 

surgical dressings can be kept in place with 
great difficulty only. 

A patient whose skin has been burned over 
one third of its superficial inches, may be treat- 
ed according to the following method : 

Anaesthetize the patient with chloroform. 

Have ready, a couple of the disinfected 
sponges ; a basin of 1-5,000 bichloride solu- 
tion for washing sponges ; a basin of 1-30 
carbolic-acid solution for the scissors and for- 
ceps ; a box of subnitrate of bismuth, and a 
camel's-hair brush ; a yard or two of soft linen 
cloth ; and narrow strips of rubber plaster. 

It w^U not be possible to treat these wounds 
antiseptically, but a fairly close approach to 
that condition may be brought about. 

With scissors and forceps remove all sepa- 
rated cuticle. 

Wash the surface clean with the 1-5,000 bi- 
chloride solution as you proceed, and sprinkle 
subnitrate of bismuth generously over the ex- 
posed surfaces before the bichloride solution 
has dried. 

Cover each patch of bismuth-sprinkled burn 
with a single layer of the soft linen cloth. 



HOW WE TREAT WOUNDS TO-DAY. 1 47 

Fasten each piece of cloth in place with 
short strips of rubber plaster across its corners. 

Once or twice daily afterward, two of the 
corners of each piece of cloth should be loos- 
ened. 

Lift up the cloth. 

Gently detach the shell of subnitrate of bis- 
muth which covers a little collection of dis- 
charge. 

Sprinkle on enough fresh bismuth to absorb 
the remaining discharge at that point. 

Do not touch the wounds. 

The discharge will be very sm.all in quantity, 
amounting to not more than six or eight 
drachms daily when a large man is burned 
over one third of his skin. 

Usually, in a burn of this kind, some few 
points of skin will be burned to the third de- 
gree, — a portion of the thickness of the true 
skin being destroyed. 

When this is the case the destroyed part will 
become dry and horny under the subnitrate- 
of-bismuth treatment, and will separate as a 
dry slough without decomposition. 

Aid the separation with a sharp scalpel, and 



148 HOW WE TREAT WOUNDS TO-DAY, 

keep the granulations covered with fresh bis- 
muth powder. 

Whether the patient Hve or not will very 
frequently depend upon your way of handling 
the constitutional symptoms. 

General rational principles should govern 
the treatment. 

Every case will present its own peculiarities, 
and consequently I do not care to enter into 
the description of the imposing array of group- 
ings of symptoms which would be presented in 
a treatise on the treatment as a whole. 

It may be well to make a few brief sugges- 
tions however. 

During the stage of depression, which lasts 
for one or two days, the patient will remain in 
a state of shock or of collapse, unless he die 
or receive good treatment. 

Immersion in a bath-tub of warm water will 
bring such a patient temporarily into a com- 
paratively comfortable condition. 

Stimulation on general principles must fol- 
low. Chloroform given to the surgical degree 
will usually relieve the condition of shock or 
-collapse, and if then the burns be dressed and 



HOW WE TREAT WOUNDS TO- DA )'. 1 49 

morphine given, the patient will be ready to 
improve regularly and steadily under your 
treatment. 

So soon as the second stage appears — that 
of reaction, — the bowels must be opened freely 
with a saline cathartic. 

The congested kidneys must receive atten- 
tion through citrate of potassium and digitalis 
and thorough cupping or poulticing. 

Vomiting may be controlled with belladonna. 

Nutrition should be exclusively through 
rectal enemata of peptonised milk for a few 
days. 

Do not make the thoughtless mistake of 
adding raw ^^<g or any other undigested food 
material to the enema. 

If a sudden failing during the second stage 
should be associated with absence of liver dul- 
ness — showing escape of gas into the peritoneal 
cavity, — you would expect to make a diagnosis 
of perforating duodenal ulcer pretty promptly. 

The diaornosis havino- been made, tlic indi- 
cation would seem to be for laparotomy o\\ the 
spot, with resection of intestine, or closure of 
the perforations by means of Lembert's suture. 



ISO HOW WE TREAT WOUNDS TO-DAY, 

I do not know that any one has done this as 
yet, but it should have been done, just as 
surely as operation in case of perforating ulcer 
of the stomach should have been done. 

The reason for employing the described 
method of local treatment in an extensive burn 
of the second degree is as follows : 

1 . Anaesthetizing the patient with chloroform 
brings him out of the condition of shock. 

Dressing the wounds during sleep adds 
nothing to the shock. 

2. Removal of separated cuticle disposes of 
dead animal matter, which would decompose if 
left in contact with the wound. 

3. Washing with 1-5,000 bichloride solution 
removes microbe food, and checks the develop- 
ment of microbes to a certain extent. 

4. Subnitrate of bismuth is a bland and un- 
irritating wound dressing. 

It is a tolerably good antiseptic because it 
dries the discharges. 

Its slight astringency stimulates. 

The discharge from the wound unites the 
powder in the form of a crust which fits like 
new skin. 



HOW WE TREAT WOUNDS TO-DAY, 151 

5. The single layer of linen cloth protects 
the loose bismuth powder, and allows of drying 
of the absorbed discharge, while the cloth 
itself remains clean, or nearly so. 

Class 6, Burned Wound ; Variety 3, A 
Limited Burn of the Third or Fourth De- 
gree. 

A burn of the third degree, in which the 
true skin is destroyed through a part of its 
thickness ; or a burn of the fourth degree, in 
which the true skin is destroyed through its 
entire thickness, is often caused by a strong 
mineral acid or by boiling or burning oil. 

A laborer accidentally spills boiling oil over 
his hand and wrist, and comes to you at once 
for treatment. 

A few blebs remain at the upper part of the 
wound, but the cuticle lies in loose folds below 
that point, and serum is being exuded rapidly. 

The exposed true skin is unnaturally w^hite, 
or unnaturally red. 

From the character of the injury the true 
skin is supposed to be destroyed through a 
part or a whole of its thickness. 



152 HOW WE TREAT WOUNDS TO-DAY. 

Submerge the hand and wrist in a bowl of 
warm 1-5,000 bichloride-of-mercury solution. 

Remove all of the loose cuticle, and open 
the blebs, cutting away the cuticle which 
helped form them. 

Take the hand out of the bowl and put it 
on a towel wrung out in 1-1,000 bichloride 
solution. 

Wash your own hands in bichloride solution 
of the same strength. 

Remove the smallest pieces of remaining 
loose cuticle. 

They can do only harm by their presence. 

Gently shave the unburned skin in the 
vicinity of the wrist. 

Put the hand and wrist in a fresh bowl of 
warm 1-5,000 bichloride solution, and wait for 
five minutes. 

Lay the hand and wrist again on the disin- 
fected towel. 

Sprinkle iodoform over any palmar cuticle 
which may remain attached. 

In a bowl of 1-5,000 bichloride solution 
wash the carbolic-acid solution from strips of 
Lister protective. 



HO W WE TREA T WO UNDS TO-DA V, 153 

Wind the protective very smoothly about 
the fingers, hand, and wrist. 

Sprinkle iodoform over all. 

Wrap a thick layer of bichloride gauze about 
the hand and lower part of the arm. 

Cover the gauze with bichloride cotton. 

Bandage snugly. 

Lay the hand in its dressing on the oppo- 
site shoulder, and hold it there by means of 
bandages for two or three days. 

Don't change the dressing until a decompo- 
sition odor is noticed about it. 

This odor should not be found until ten days 
or two weeks have passed. 

When you change the dressing, put the 
hand in a basin of warm 1-5,000 bichloride 
solution. 

Trim away loose slough with a sharp scalpel 
and a pair of forceps. 

Rub iodoform into any remaining slough. 

Dress as before. 

Leave untouched as before. 

Change as before. 

Plant skin-grafts on large granulating sur- 
faces after all sloucrh has been removed. 



154 HOW WE TREAT WOUNDS TO-DA V. 

The amount of suppuration from this wound 
should be trifling, and seldom sufficient to ne- 
cessite a change of dressing on its account. 

If a case similar to the above has been 
treated in some ordinary way, and large gran- 
ulating surfaces are struggling to furnish 
enough pus to float off" the unwelcome dress- 
ings, the method of dressing would be after 
the following order : 

Wash away the pus with syringefuls of warm 
1-5,000 bichloride solution. 

Mix fluid extract of ergot with equal parts 
of warm water. 

Squeeze this solution from a sponge over 
the whole granulating surface. 

It will cause smarting for a moment. 

Dress with disinfected Lister protective, 
iodoform, and bichloride cotton. 

Repeat the process once daily until the daily 
dressing can be deferred, and change afterward 
as seldom as possible. 

Profuse suppuration will sometimes be cut 
short with one such application of ergot. 

The reason for this is probably because the 
ergot produces a local stimulation of the vaso- 



HO W WE TREA T WOUNDS TO-DA Y, I 5 5 

motor nerve filaments, causing a condition of 
high tension in the blood-vessels of the wound, 
and thereby stopping the transmigration of 
leucocytes, which can not easily pass through 
these vessel walls. 

In one case of mine, both of the hands and 
wrists were badly burned, and several ounces 
of pus were being daily thrown off from ugly, 
misshapen granulating surfaces. 

I experimented here by using ergot, protec- 
tive, and gauze, on the left hand, and a dress- 
ing of iodoform and vaseline, spread on sheet 
lint, for the right hand. 

The discharge from the left extremity was 
reduced from ounces to drachms in twenty- 
four hours, and in a week nearly all of the 
granulating surface had contracted firmly, and 
was covered with a delicate pearly-blue film of 
exquisite new epithelium. 

The right hand and wrist remained in their 
former condition, with hardly an appreciable 
attempt at repair, until, at the end of a week. 
I commenced proper treatment. The result 
of this treatment was as marked as it had been 
with the left hand. 



156 HOW WE TREA T WO UNDS TO-DA Y. 

Suppuration from a flat surface, or from a 
surface covered with ill-defined granulations, is 
not so easily controlled. 

In well-managed burned wounds, suppura- 
tion requiring special treatment will n*ot occur. 

Class 6, Burned Wounds ; Variety 4, An 
Extensive Burn of the Third and Fourth De- 
grees. 

When a woman's dress catches fire, a portion 
of her skin is usually burned to the third and 
fourth degrees. 

In the majority of cases the burn extends 
from the tops of the shoes to the waist ; and 
from the ends of the fingers to the line where 
the sleeve encircles the arm. 

Sometimes a part of the skin about the face 
is scorched, although in several of the cases of 
the kind which I have treated the face has not 
been burned. 

A serious degree of shock follows such a 
burn. 

If you have not sufficient confidence in 
chloroform as a shock reliever in a case of the 
kind, put the patient — clothes and all — into a 



HO W WE TREA T WO UNDS TO-DA V. 157 

bath-tub full of water, at the temperature of 
about 1 10° F. 

Anaesthetize so soon as the marked signs of 
shock have been relieved. 

The best way is to give chloroform at once, 
and to the surgical degree. 

When this has been done, remove all cloth- 
ing. Do not remove any of the clothing be- 
fore giving the chloroform. 

Put the patient on the table with the rubber 
sheet under her. 

Irrigate with 1-2,000 bichloride of mercury 
while you remove every particle of loosened 
and destroyed cuticle and all adhering bits of 
burned cloth. 

Scrub the burned surfaces gently but thor- 
oughly with a disinfected sponge, while 1-2,000 
bichloride solution, poured in a large stream 
from a pitcher, carries off every thing which 
the sponge loosens. 

Shave the unburned skin in the vicinity of 
the burned regions. 

Give a final flushing with 1-2,000 bichloride 
solution. 

Wipe the rubber sheet as dry and clean as 
possible. 



158 HO W WE TREA T WO UNDS TO-DA Y, 

Wring out several towels in a washbowl 
full of 1-2,000 bichloride-of-mercury solution. 
Spread them out on the rubber sheet under 
the patient. 

Scrub your hands in 1-2,000 bichloride so- 
lution. 

Wash the burned surfaces with a liberal 
amount of 1-5,000 bichloride solution. 

Remove long three-inch-wide strips of Lister 
protective from the 1-30 carbolic-acid solution, 
and wash them off in the 1-5,000 bichloride-of- 
mercury solution. 

Be careful that the strips of protective touch 
nothing which is not disinfected. 

Wind them smoothly and in a single layer 
around the legs, and lay shorter pieces upon 
the buttocks. 

A catgut suture here and there through the 
skin will hold in place such pieces of protective 
as would be inclined to slip. 

Tear the protective in narrow strips for the 
hands and arms. 

Sprinkle iodoform along all margins of pro- 
tective. 

Cover all applied protective with a two-inch- 



HOJV IVE TREAT WOUNDS TO-DA Y. I 59 

thick layer of bichloride gauze, and allow the 
gauze to project proximally and distally for 
several inches beyond the limits of the pro- 
tective. 

Fasten the gauze snugly in place with a bi- 
chloride gauze bandage. 

Apply over this a three-inch-thick layer of 
bichloride cotton. 

Bandage rather firmly. 

The burns about the face will probably be 
of the first degree, and should be treated b\' 
applying ordinary oil-mixed white paint on 
strips of old linen. 

Cover the dressing with gutta-percha tissue 
to keep it from drying, and for neatness' sake. 

White paint relieves the pain more quickh" 
and completely than any other substance which 
I have employed. 

If the patient can now be slung in a ham- 
mock, we have an ideal condition of things. 

The limbs can be elevated ; the catheter can 
be used, and the rectal nutrient enemata are 
easily given, several hammock strands having 
been cut. Additional dressing ma\ be added 
where serum runs thn^ugh tlie pcrnKinent one ; 



l6o HO IV WE TREAT WOUNDS TO-DAY. 

and all with a minimum degree of disturbance 
to the patient. 

Moreover, the dressings dry evenly on all 
sides, so that the unwished-for poultice-like 
effect of collections of serum under the but- 
tocks is avoided. 

If it is not convenient to put the patient in 
a hammock, the layer of bichloride cotton will 
probably have to be changed in two or three 
days, on account of serous saturation. 

Carefully avoid disturbing the gauze and 
deeper parts of the dressing when the bichlo- 
ride cotton layer is removed. 

In treaiting the all-important constitutional 
symptoms, a reference to the suggestions made 
on page io8 will be in order. 

Remove all dressings from the wounds for 
the first time, when a decomposition odor is 
noticed. 

This odor should not appear before the end 
of the second week. 

Change the dressings under irrigation with 
1-5,000 bichloride-of-mercury solution, and 
anaesthetize the patient for the occasion. 

A large part of the burn will have been of 



HOW WE TREAT WOUNDS TO-DAY. l6l 

the second degree, and this part will be healed 
or nearly so. 

Cut away loosened margins and the upper 
surfaces of the sloughs with a sharp scalpel, 
and rub iodoform into the remainder of each 
slough. 

If the parts which were burned to the second 
degree are not healed, the original dressing 
must be renewed, and left in place for another 
week. 

Afterward, treat the sloughs and granulating 
surfaces with subnitrate of bismuth accordine 
to the method previously described. 

Begin skin-grafting a week or two later. 

The dressings for a burn of this kind are 
rather expensive. 

But! 

Expense is not to be considered. 

And! 

The actual cost is not very different from 
the final value of dressincrs of old raQs. 



LAST WORD. 



He who has not learned some scientific^ 
antiseptic method for wound treatment has 
not learned the first principles of surgery. 

Men who have learned such a method will, 
after a series of brilliant results, begin to relax 
from the severity of their carefulness. 

They will believe that certain details may be 
omitted. 

Before long they have suppuration in a 
wound which they did not care to have sup- 
puration in, or they fail to get primary union 
in a case where primary union was expected. 
As a result they will either lose a little of their 
faith in the infallibility of antiseptic measures, 
or they will, appreciating their position, reason 
back from effect to cause. 

Whether a man screw himself up to the 
right key or not, depends upon the comprehen- 
siveness of that man's intellection. 

Remember that the relaxation from a con- 
dition of vigilance is sure to come. 

Beware of failure to recover. 
162 



